MEDICARE: ALLIANCE PHYSICIAN GROUP LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	302F00000X	Exclusive Provider Organization		FL

General Provider Information

NPI Number	:	1104226158
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ALLIANCE PHYSICIAN GROUP LLC

Provider Business Mailing Address
First Line	:	855 SAINT JOHNS BLUFF RD N
Second Line	:	SKY HARBOR, UNIT 703
City	:	JACKSONVILLE
State	:	FL
Zip	:	32225-7309
Country	:	US
Telephone Number	:	800-991-6508
Fax Number	:

Provider Business Practice Location Address
First Line	:	855 SAINT JOHNS BLUFF RD N
Second Line	:	SKY HARBOR, UNIT 703
City	:	JACKSONVILLE
State	:	FL
Zip	:	32225-7309
Country	:	US
Telephone Number	:	800-991-6508
Fax Number	:

Authorized Official
Title or Position	:	DIRECTOR
Name	:	ANDREW ERIKSEN
Credential	:
Telephone Number	:	904-746-4664

Provider Enumeration Date	:	08/27/2014
Last Update Date	:	08/27/2014

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