Healthcare Provider Details

I. General information

NPI: 1891748257
Provider Name (Legal Business Name): FLORIDA PROTON THERAPY INSTITUTE INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/18/2006
Last Update Date: 12/05/2024
Certification Date: 12/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2015 JEFFERSON ST
JACKSONVILLE FL
32206-3531
US

IV. Provider business mailing address

2015 JEFFERSON ST
JACKSONVILLE FL
32206-3531
US

V. Phone/Fax

Practice location:
  • Phone: 904-588-1263
  • Fax: 904-588-1300
Mailing address:
  • Phone: 904-588-1401
  • Fax: 904-588-1437

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0001X
TaxonomyRadiation Oncology Physician
License NumberME39054
License Number StateFL

VIII. Authorized Official

Name: NANCY MEDENHALL
Title or Position: DIRECTOR, ACTIVE, ATTENDING
Credential: MD
Phone: 904-588-1401