Healthcare Provider Details

I. General information

NPI: 1053845099
Provider Name (Legal Business Name): JENA MEDICAL GROUP, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/17/2017
Last Update Date: 02/03/2021
Certification Date: 11/25/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

926 SAXON BLVD
ORANGE CITY FL
32763-8313
US

IV. Provider business mailing address

302 ADAMS CT
EDGEWATER NJ
07020-1655
US

V. Phone/Fax

Practice location:
  • Phone: 386-774-1881
  • Fax: 386-774-1264
Mailing address:
  • Phone: 347-542-6360
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207KA0200X
TaxonomyAllergy Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. BENJAMIN WEISS
Title or Position: PRESIDENT
Credential:
Phone: 347-542-6360