Healthcare Provider Details

I. General information

NPI: 1811927650
Provider Name (Legal Business Name): MEMORIAL NEUROSURGERY GROUP LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/04/2006
Last Update Date: 11/02/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4063 SALISBURY RD SUITE 210
JACKSONVILLE FL
32216-8030
US

IV. Provider business mailing address

4063 SALISBURY RD SUITE 210
JACKSONVILLE FL
32216-8030
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: VICE PRESIDENT
Credential:
Phone: 850-523-2117