Basic Information
| Provider Information | |||||||||
| NPI: | 1215078977 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | REGIONAL OBSTETRIC CONSULTANTS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 836 PRUDENTIAL DR | ||||||||
| Address2: | SUITE 1800 | ||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322078334 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9043987684 | ||||||||
| FaxNumber: | 9043984998 | ||||||||
| Practice Location | |||||||||
| Address1: | 836 PRUDENTIAL DR | ||||||||
| Address2: | SUITE 1800 | ||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322078334 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9043987684 | ||||||||
| FaxNumber: | 9043984998 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/08/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | THRASHER | ||||||||
| AuthorizedOfficialFirstName: | DIANE | ||||||||
| AuthorizedOfficialMiddleName: | KAYE | ||||||||
| AuthorizedOfficialTitleorPosition: | OFFICE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 9043987684 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207VM0101X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Maternal & Fetal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 77611 | 01 | FL | BLUE CROSS BLUE SHHIELD | OTHER |