Healthcare Provider Details

I. General information

NPI: 1942504055
Provider Name (Legal Business Name): ST. VINCENT'S INTENSIVISTS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/04/2011
Last Update Date: 01/04/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 SHIRCLIFF WAY
JACKSONVILLE FL
32204-4748
US

IV. Provider business mailing address

425 N LEE ST SUITE 203
JACKSONVILLE FL
32204-1127
US

V. Phone/Fax

Practice location:
  • Phone: 904-354-8200
  • Fax: 904-354-1340
Mailing address:
  • Phone: 904-354-8200
  • Fax: 904-354-1340

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. DANIEL WYZAN
Title or Position: PRESIDENT
Credential: M.D.
Phone: 904-354-8200