Healthcare Provider Details

I. General information

NPI: 1679868467
Provider Name (Legal Business Name): MOUNT GILEAD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/09/2011
Last Update Date: 06/09/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6817 SOUTHPOINT PKWY SUITE 304
JACKSONVILLE FL
32216-6282
US

IV. Provider business mailing address

6817 SOUTHPOINT PKWY SUITE 304
JACKSONVILLE FL
32216-6282
US

V. Phone/Fax

Practice location:
  • Phone: 904-296-3113
  • Fax: 904-296-3144
Mailing address:
  • Phone: 904-296-3113
  • Fax: 904-296-3144

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number603914
License Number StateFL

VIII. Authorized Official

Name: DR. THOMAS CAREY MERRITT
Title or Position: PRESIDENT
Credential: MD
Phone: 904-296-3113