=====================================================
General NPI Number Information
=====================================================
NPI Number | 1013291517
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MEDICAL PARTNERS OF JACKSONVILLE LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/03/2011
-----------------------------------------------------
Last Update Date | 10/03/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1564 KINGSLEY AVE
-----------------------------------------------------
City | ORANGE PARK
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32073-4511
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-830-4083
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1564 KINGSLEY AVE
-----------------------------------------------------
City | ORANGE PARK
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32073-4511
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-830-4083
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | HEMANT SHAH
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 904-830-4083
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208VP0014X
-----------------------------------------------------
Taxonomy Name | Interventional Pain Medicine Physician
-----------------------------------------------------
License Number | ME95262
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------