Healthcare Provider Details

I. General information

NPI: 1316038615
Provider Name (Legal Business Name): JACK LEELAND GREIDER JR. M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/28/2006
Last Update Date: 10/25/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6100 KENNERLY RD SUITE 202
JACKSONVILLE FL
32216-4368
US

IV. Provider business mailing address

6100 KENNERLY RD SUITE 202
JACKSONVILLE FL
32216-4368
US

V. Phone/Fax

Practice location:
  • Phone: 904-733-5550
  • Fax: 904-733-5515
Mailing address:
  • Phone: 904-733-5550
  • Fax: 904-733-5515

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207XS0106X
TaxonomyOrthopaedic Hand Surgery Physician
License NumberME27693
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: