Healthcare Provider Details

I. General information

NPI: 1487860284
Provider Name (Legal Business Name): MEMORIAL NEUROSURGERY GROUP LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/16/2007
Last Update Date: 01/21/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3627 UNIVERSITY BLVD S SUITE 355
JACKSONVILLE FL
32216-4230
US

IV. Provider business mailing address

3627 UNIVERSITY BLVD S SUITE 355
JACKSONVILLE FL
32216-4230
US

V. Phone/Fax

Practice location:
  • Phone: 904-296-2522
  • Fax: 904-296-8173
Mailing address:
  • Phone: 904-296-2522
  • Fax: 904-296-8173

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207T00000X
TaxonomyNeurological Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: MICKEY PICKLER
Title or Position: VP
Credential:
Phone: 850-523-2117