Healthcare Provider Details

I. General information

NPI: 1275150971
Provider Name (Legal Business Name): ETHAN ALEXANDER HILES
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/29/2020
Last Update Date: 04/30/2024
Certification Date: 04/30/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2001 KINGSLEY AVE
ORANGE PARK FL
32073-5148
US

IV. Provider business mailing address

2265 KRAFT DR
BLACKSBURG VA
24060-6360
US

V. Phone/Fax

Practice location:
  • Phone: 904-639-8500
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number34.017166
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: