Healthcare Provider Details

I. General information

NPI: 1033542485
Provider Name (Legal Business Name): EMORY MEDICAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/20/2013
Last Update Date: 08/22/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1546 S WATER ST STE. A
STARKE FL
32091-4511
US

IV. Provider business mailing address

PO BOX 1646
LAKE CITY FL
32056-1646
US

V. Phone/Fax

Practice location:
  • Phone: 904-964-4777
  • Fax: 904-964-4780
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number2093
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QR1300X
TaxonomyRural Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MRS. AMANDA BOLT
Title or Position: OFFICE MANAGER
Credential:
Phone: 386-466-1106