Healthcare Provider Details

I. General information

NPI: 1447767686
Provider Name (Legal Business Name): ST. JOHNS INTERVENTIONAL AND VASCULAR INSTITUTE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/09/2018
Last Update Date: 06/03/2021
Certification Date: 06/03/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8767 PERIMETER PARK BLVD
JACKSONVILLE FL
32216-5479
US

IV. Provider business mailing address

8767 PERIMETER PARK BLVD
JACKSONVILLE FL
32216-5479
US

V. Phone/Fax

Practice location:
  • Phone: 904-402-8346
  • Fax: 904-402-8347
Mailing address:
  • Phone: 904-402-8346
  • Fax: 904-402-8347

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code202K00000X
TaxonomyPhlebology Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License Number
License Number State

VIII. Authorized Official

Name: JAMES K ST. GEORGE
Title or Position: CEO
Credential: M.D.
Phone: 904-402-8346