Healthcare Provider Details

I. General information

NPI: 1902851264
Provider Name (Legal Business Name): GAINESVILLE GYN ONCOLOGY OF NORTH FLORIDA REGIONAL MEDICAL CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/24/2006
Last Update Date: 09/09/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6400 W NEWBERRY RD SUITE 103
GAINESVILLE FL
32605-4384
US

IV. Provider business mailing address

6400 W NEWBERRY RD SUITE 103
GAINESVILLE FL
32605-4384
US

V. Phone/Fax

Practice location:
  • Phone: 352-333-5946
  • Fax: 352-333-5947
Mailing address:
  • Phone: 352-333-5946
  • Fax: 352-333-5947

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207VX0201X
TaxonomyGynecologic Oncology Physician
License NumberME73553
License Number StateFL

VIII. Authorized Official

Name: MR. WILLIAM T JOHNSON
Title or Position: VICE PRESIDENT
Credential:
Phone: 615-372-3375