Healthcare Provider Details

I. General information

NPI: 1144117839
Provider Name (Legal Business Name): GNM MD, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/23/2025
Last Update Date: 07/01/2025
Certification Date: 07/01/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

112 BARTRAM OAKS WALK UNIT 600849
SAINT JOHNS FL
32260-7734
US

IV. Provider business mailing address

112 BARTRAM OAKS WALK UNIT 600849
SAINT JOHNS FL
32260-7734
US

V. Phone/Fax

Practice location:
  • Phone: 904-834-5175
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207SG0201X
TaxonomyClinical Genetics (M.D.) Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: ANTHONY PERSZYK
Title or Position: OWNER
Credential: MD
Phone: 904-834-5175