Provider Demographics
NPI:1568359792
Name:NORTHEAST FLORIDA WOUND CURE AND HYPERBARIC MEDICINE PLLC
Entity type:Organization
Organization Name:NORTHEAST FLORIDA WOUND CURE AND HYPERBARIC MEDICINE PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:COURTNEY
Authorized Official - Middle Name:BLAIR
Authorized Official - Last Name:FAHNHORST VIDRINE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:612-310-8971
Mailing Address - Street 1:101 MARKETSIDE AVE STE 404
Mailing Address - Street 2:
Mailing Address - City:PONTE VEDRA
Mailing Address - State:FL
Mailing Address - Zip Code:32081-1542
Mailing Address - Country:US
Mailing Address - Phone:612-310-8971
Mailing Address - Fax:
Practice Address - Street 1:205 TRINITY WAY STE 3800
Practice Address - Street 2:
Practice Address - City:ST JOHNS
Practice Address - State:FL
Practice Address - Zip Code:32259-1155
Practice Address - Country:US
Practice Address - Phone:612-310-8971
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-06-20
Last Update Date:2025-07-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207PE0005XAllopathic & Osteopathic PhysiciansEmergency MedicineUndersea and Hyperbaric MedicineGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty