1124176540 NPI number — JACKSONVILLE ORTHOPAEDIC INSTITUTE INC

Table of content: (NPI 1124176540)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1124176540 NPI number — JACKSONVILLE ORTHOPAEDIC INSTITUTE INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
JACKSONVILLE ORTHOPAEDIC INSTITUTE INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
JACKSONVILLE ORTHOPAEDIC INSTITUTE REHABILITATION
Provider Other Organization Name Type Code:
5
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1124176540
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/08/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 117345
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ATLANTA
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30368-7345
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
904-346-3465
Provider Business Mailing Address Fax Number:
904-858-6489

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1325 SAN MARCO BLVD
Provider Second Line Business Practice Location Address:
SUITE 102
Provider Business Practice Location Address City Name:
JACKSONVILLE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32207-8568
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
904-557-9021
Provider Business Practice Location Address Fax Number:
904-557-9022
Provider Enumeration Date:
01/08/2007

Additional Information

Authorized Official

Authorized Official Last Name:
WALL
Authorized Official First Name:
TIMOTHY
Authorized Official Middle Name:
EDWIN
Authorized Official Title or Position:
ADMINISTRATOR
Authorized Official Telephone Number:
904-858-7045

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 2255A2300X , with the licence number: AL351 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 225X00000X , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)





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