Healthcare Provider Details

I. General information

NPI: 1356497572
Provider Name (Legal Business Name): FLORIDA MULTI SPECIALTY MEDICAL GROUP, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/29/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1561 CASSAT AVE
JACKSONVILLE FL
32210-1701
US

IV. Provider business mailing address

1561 CASSAT AVE
JACKSONVILLE FL
32210-1701
US

V. Phone/Fax

Practice location:
  • Phone: 904-389-5193
  • Fax: 904-389-5227
Mailing address:
  • Phone: 904-389-5193
  • Fax: 904-389-5227

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number
License Number State

VIII. Authorized Official

Name: TODD MCCLERREN
Title or Position: PRESIDENT
Credential: DC
Phone: 904-389-5193