=====================================================
General NPI Number Information
=====================================================
NPI Number | 1043982606
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | VIKRAMBEHERALLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/01/2021
-----------------------------------------------------
Last Update Date | 04/04/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 801 OAK ST
-----------------------------------------------------
City | GREEN COVE SPRINGS
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32043-4317
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-284-9230
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 84 WATERLINE DR
-----------------------------------------------------
City | ST JOHNS
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32259-2311
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 212-767-9891
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMIN
-----------------------------------------------------
Name | JUDY PAYNE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 904-387-4778
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------