Basic Information
| Provider Information | |||||||||
| NPI: | 1962468892 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | COLEY | ||||||||
| FirstName: | PAUL | ||||||||
| MiddleName: | ANDREW | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | COLEY | ||||||||
| OtherFirstName: | P. | ||||||||
| OtherMiddleName: | ANDREW | ||||||||
| OtherNamePrefix: | DR. | ||||||||
| OtherNameSuffix: | JR. | ||||||||
| OtherCredential: | M.D. | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 8773 PERIMETER PARK CT | ||||||||
| Address2: | |||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322161165 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9044933390 | ||||||||
| FaxNumber: | 9044933395 | ||||||||
| Practice Location | |||||||||
| Address1: | 3627 UNIVERSITY BLVD S STE 300 | ||||||||
| Address2: | |||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 32216 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9043960300 | ||||||||
| FaxNumber: | 9043963039 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/20/2006 | ||||||||
| LastUpdateDate: | 08/20/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0200X | ME24172 | FL | N | Allopathic & Osteopathic Physicians | Internal Medicine | Critical Care Medicine | 207RI0200X | ME24172 | FL | N | Allopathic & Osteopathic Physicians | Internal Medicine | Infectious Disease | 207RP1001X | ME24172 | FL | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Pulmonary Disease |
ID Information
| ID | Type | State | Issuer | Description | 40079 | 01 | FL | AVMED | OTHER | GR172A | 01 | FL | MEDICARE - GROUP | OTHER | 0098365-00 | 01 | FL | FL MEDICAID - GROUP | OTHER | 407111035 | 01 | FL | RR MEDICARE | OTHER | 15339 | 01 | FL | FL BLUE | OTHER | 052627400 | 05 | FL | MEDICAID | 15339Y | 01 | FL | MEDICARE - INDIVIDUAL | OTHER | 146184 | 01 | FL | WELLCARE | OTHER |