Healthcare Provider Details

I. General information

NPI: 1417905993
Provider Name (Legal Business Name): SOUTHEAST GYNECOLOGIC ONCOLOGY ASSOCIATES PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/05/2006
Last Update Date: 07/01/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

915 W MONROE ST #300
JACKSONVILLE FL
32204-1149
US

IV. Provider business mailing address

915 W MONROE ST #300
JACKSONVILLE FL
32204-1149
US

V. Phone/Fax

Practice location:
  • Phone: 904-389-3993
  • Fax: 904-389-3994
Mailing address:
  • Phone: 904-389-3993
  • Fax: 904-389-3994

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207VX0201X
TaxonomyGynecologic Oncology Physician
License Number
License Number State

VIII. Authorized Official

Name: MRS. BRENDA DAVIS
Title or Position: ADMINISTRATOR
Credential:
Phone: 904-389-3993