=====================================================
General NPI Number Information
=====================================================
NPI Number | 1104094853
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | KEVIN M MCAULIFFE MD PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/15/2008
-----------------------------------------------------
Last Update Date | 03/03/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9925 SAN JOSE BLVD
-----------------------------------------------------
City | JACKSONVILLE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32257-5851
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-268-7400
-----------------------------------------------------
Fax | 904-268-7375
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9925 SAN JOSE BLVD
-----------------------------------------------------
City | JACKSONVILLE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32257-5851
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-268-7400
-----------------------------------------------------
Fax | 904-268-7375
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | KEVIN M MCAULIFFE
-----------------------------------------------------
Credential | MD PA
-----------------------------------------------------
Telephone | 904-268-7400
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207W00000X
-----------------------------------------------------
Taxonomy Name | Ophthalmology Physician
-----------------------------------------------------
License Number | 0033893
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------