1619341039 NPI number — JACKSONVILLE MEDICAL GROUP, LLC

Table of content: (NPI 1619341039)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1619341039 NPI number — JACKSONVILLE MEDICAL GROUP, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
JACKSONVILLE MEDICAL GROUP, LLC
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:
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:
1619341039
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/20/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
396 N LOMBARDY LOOP
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
JACKSONVILLE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32259-5266
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1409 KINGSLEY AVE
Provider Second Line Business Practice Location Address:
SUITE 9G
Provider Business Practice Location Address City Name:
ORANGE PARK
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32073-4537
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
904-637-0037
Provider Business Practice Location Address Fax Number:
904-639-6017
Provider Enumeration Date:
11/23/2015

Additional Information

Authorized Official

Authorized Official Last Name:
SOLEYMANI
Authorized Official First Name:
SAMAN
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
904-962-7396

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  ME88018 , registered in the state of ZZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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