1639267222 NPI number — SHANDS JACKSONVILLE MEDICAL CENTER INC

Table of content: (NPI 1639267222)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1639267222 NPI number — SHANDS JACKSONVILLE MEDICAL CENTER INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SHANDS JACKSONVILLE MEDICAL CENTER 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:
SHANDS JACKSONVILLE AMBULATORY PHARMACY
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:
1639267222
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/06/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
655 W 8TH ST
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:
32209-6511
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
904-244-8675
Provider Business Mailing Address Fax Number:
904-244-4027

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
655 W 8TH ST
Provider Second Line Business Practice Location Address:
1ST FLOOR, ACC BLDG.
Provider Business Practice Location Address City Name:
JACKSONVILLE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32209-6511
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
904-244-4542
Provider Business Practice Location Address Fax Number:
904-244-4998
Provider Enumeration Date:
10/10/2006

Additional Information

Authorized Official

Authorized Official Last Name:
COCCHI
Authorized Official First Name:
DEAN
Authorized Official Middle Name:
Authorized Official Title or Position:
VICE PRESIDENT AND CFO OF FINANCE
Authorized Official Telephone Number:
904-244-5013

Provider Taxonomy Codes

  • Taxonomy code: 333600000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 3336C0003X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336S0011X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 0217042-00 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1029164 . This is a "NCPDP" identifier . This identifiers is of the category "OTHER".
  • Identifier: PH16886 . This is a "PHARMACY LICENSE NUMBER" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".




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