Provider Demographics
NPI:1518775873
Name:INTERCOASTAL HEALTH
Entity type:Organization
Organization Name:INTERCOASTAL HEALTH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:PETER
Authorized Official - Middle Name:CHRISTOPHER
Authorized Official - Last Name:MCDERMOTT
Authorized Official - Suffix:
Authorized Official - Credentials:APRN
Authorized Official - Phone:904-799-2531
Mailing Address - Street 1:4320 DEERWOOD LAKE PKWY STE 327
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32216-1177
Mailing Address - Country:US
Mailing Address - Phone:904-799-2531
Mailing Address - Fax:904-659-8558
Practice Address - Street 1:4320 DEERWOOD LAKE PKWY STE 327
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32216-1177
Practice Address - Country:US
Practice Address - Phone:904-799-2531
Practice Address - Fax:904-659-8558
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-12-19
Last Update Date:2024-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service