MEDICARE: LIGHTHOUSE INTERNAL MEDICINE AND PRIMARY CARE PA

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	207R00000X	Internal Medicine Physician	ME92689	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	40311	OTHER	FL	BCBS FL
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
4	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1588742977
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LIGHTHOUSE INTERNAL MEDICINE AND PRIMARY CARE PA

Provider Business Mailing Address
First Line	:	5757 BOOTH RD BLDG 200
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32207-5981
Country	:	US
Telephone Number	:	904-636-9510
Fax Number	:	904-636-9512

Provider Business Practice Location Address
First Line	:	5757 BOOTH RD.
Second Line	:	#200
City	:	JACKSONVILLE
State	:	FL
Zip	:	32207
Country	:	US
Telephone Number	:	904-636-9510
Fax Number	:	904-636-9512

Authorized Official
Title or Position	:	MD
Name	:	CHONGLUN XIE
Credential	:
Telephone Number	:	904-636-9510

Provider Enumeration Date	:	11/01/2006
Last Update Date	:	09/21/2018

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Directions to “LIGHTHOUSE INTERNAL MEDICINE AND PRIMARY CARE PA ” Practice Location

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