=====================================================
General NPI Number Information
=====================================================
NPI Number | 1003588344
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SACRED HEART MEDICAL GROUP
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/05/2021
-----------------------------------------------------
Last Update Date | 10/05/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 730 BAYFRONT PKWY STE 4A
-----------------------------------------------------
City | PENSACOLA
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32502-6250
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 850-432-5488
-----------------------------------------------------
Fax | 850-432-5228
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4205 BELFORT RD STE 4015
-----------------------------------------------------
City | JACKSONVILLE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32216-3623
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR-MANAGED CARE
-----------------------------------------------------
Name | JEAN VALLIER
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 850-432-5488
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2086X0206X
-----------------------------------------------------
Taxonomy Name | Surgical Oncology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------