MEDICARE: DR. JACK JERRY SALAH 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	207RP1001X	Pulmonary Disease Physician	ME0041346	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1336140938
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JACK JERRY SALAH M.D.

Provider Business Mailing Address
First Line	:	8236 SHADY GROVE RD
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32256-7361
Country	:	US
Telephone Number	:	904-645-9655
Fax Number	:

Provider Business Practice Location Address
First Line	:	3599 UNIVERSITY BLVD S
Second Line	:	SUITE 901
City	:	JACKSONVILLE
State	:	FL
Zip	:	32216-4252
Country	:	US
Telephone Number	:	904-398-6971
Fax Number	:	904-398-2497

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/03/2005
Last Update Date	:	01/25/2010

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