MEDICARE: JOSEPH SACKETT, M.D.

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	261QR0200X	Radiology Clinic/Center	18916-20	WI

General Provider Information

NPI Number	:	1326479056
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	JOSEPH SACKETT, M.D.

Provider Business Mailing Address
First Line	:	611 PONTE VEDRA BLVD
Second Line	:	UNIT 122
City	:	PONTE VEDRA BEACH
State	:	FL
Zip	:	32082-4730
Country	:	US
Telephone Number	:	904-280-4388
Fax Number	:	904-280-0807

Provider Business Practice Location Address
First Line	:	611 PONTE VEDRA BLVD
Second Line	:	UNIT 122
City	:	PONTE VEDRA BEACH
State	:	FL
Zip	:	32082-4730
Country	:	US
Telephone Number	:	904-280-4388
Fax Number	:	904-280-0807

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. JOSEPH FREDERIC SACKETT
Credential	:	MD
Telephone Number	:	904-280-4388

Provider Enumeration Date	:	12/05/2013
Last Update Date	:	12/05/2013

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