1962484220 NPI number — SOUTHERN HEART GROUP

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1962484220 NPI number — SOUTHERN HEART GROUP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SOUTHERN HEART GROUP
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:
Provider Other Organization Name Type Code:
6
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:
1962484220
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/22/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
562 PARK ST
Provider Second Line Business Mailing Address:
SUITE 310
Provider Business Mailing Address City Name:
JACKSONVILLE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32204-2918
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
904-633-2021
Provider Business Mailing Address Fax Number:
904-633-9793

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1824 KING ST
Provider Second Line Business Practice Location Address:
SUITE 300
Provider Business Practice Location Address City Name:
JACKSONVILLE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32204-4735
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
904-388-1820
Provider Business Practice Location Address Fax Number:
904-388-1827
Provider Enumeration Date:
11/14/2005

Additional Information

Authorized Official

Authorized Official Last Name:
PILCHER
Authorized Official First Name:
GEORGE
Authorized Official Middle Name:
S
Authorized Official Title or Position:
MANAGING PARTNER
Authorized Official Telephone Number:
904-388-1820

Provider Taxonomy Codes

  • Taxonomy code: 207RC0000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: GRP3918 . This is a "GEORGIA MEDICARE" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: CH8079 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: CI0090 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".




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