Provider Demographics
NPI:1538735246
Name:CHILDREN'S EXPRESS CARE CLINIC
Entity type:Organization
Organization Name:CHILDREN'S EXPRESS CARE CLINIC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SUWARNA
Authorized Official - Middle Name:M
Authorized Official - Last Name:TILAK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:904-519-0008
Mailing Address - Street 1:135 DURBIN STATION CT UNIT 503
Mailing Address - Street 2:
Mailing Address - City:ST JOHNS
Mailing Address - State:FL
Mailing Address - Zip Code:32259-9370
Mailing Address - Country:US
Mailing Address - Phone:904-519-0008
Mailing Address - Fax:
Practice Address - Street 1:135 DURBIN STATION CT UNIT 503
Practice Address - Street 2:
Practice Address - City:ST JOHNS
Practice Address - State:FL
Practice Address - Zip Code:32259-9370
Practice Address - Country:US
Practice Address - Phone:904-519-0008
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CHILDREN'S EXPRESS CARE CLINIC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2021-06-02
Last Update Date:2021-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL004548500Medicaid