1326659236 NPI number — JACKSONVILLE SPINE CENTER PA

Table of content: (NPI 1326659236)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1326659236 NPI number — JACKSONVILLE SPINE CENTER PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
JACKSONVILLE SPINE CENTER PA
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:
JAX SPINE & PAIN CENTERS
Provider Other Organization Name Type Code:
3
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:
1326659236
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/26/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5191 FIRST COAST TECH PKWY
Provider Second Line Business Mailing Address:
3RD FLOOR
Provider Business Mailing Address City Name:
JACKSONVILLE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32256-5004
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
904-223-3321
Provider Business Mailing Address Fax Number:
904-223-2169

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1699 S 14TH ST STE 16
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FERNANDINA BEACH
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32034-1965
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
904-223-3321
Provider Business Practice Location Address Fax Number:
904-223-2169
Provider Enumeration Date:
08/13/2020

Additional Information

Authorized Official

Authorized Official Last Name:
GROTH
Authorized Official First Name:
ALICIA
Authorized Official Middle Name:
M
Authorized Official Title or Position:
CREDENTIALING SPECIALIST
Authorized Official Telephone Number:
904-223-3321

Provider Taxonomy Codes

  • Taxonomy code: 208VP0014X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 009250505 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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