Healthcare Provider Details

I. General information

NPI: 1083156202
Provider Name (Legal Business Name): MEMORIAL ADVANCED SURGERY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/07/2016
Last Update Date: 11/07/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3627 UNIVERSITY BLVD S STE 700
JACKSONVILLE FL
32216-7403
US

IV. Provider business mailing address

3627 UNIVERSITY BLVD S STE 700
JACKSONVILLE FL
32216-7403
US

V. Phone/Fax

Practice location:
  • Phone: 904-399-5678
  • Fax: 904-399-8488
Mailing address:
  • Phone: 904-399-5678
  • Fax: 904-399-8488

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number035676
License Number StateFL

VIII. Authorized Official

Name: MICHELLE LEWIS
Title or Position: PRACTICE MANAGER
Credential:
Phone: 904-399-5678