=====================================================
General NPI Number Information
=====================================================
NPI Number | 1104863042
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NEUROLOGY ASSOCIATES OF NORTH FLORIDA , INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/31/2006
-----------------------------------------------------
Last Update Date | 01/24/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1361 13TH AVE S STE 170A
-----------------------------------------------------
City | JACKSONVILLE BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32250-3235
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-249-4456
-----------------------------------------------------
Fax | 904-249-7703
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 17809
-----------------------------------------------------
City | JACKSONVILLE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32245-7809
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-723-0015
-----------------------------------------------------
Fax | 904-338-0951
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | RICHARD BOEHME
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 904-249-4456
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2084N0400X
-----------------------------------------------------
Taxonomy Name | Neurology Physician
-----------------------------------------------------
License Number | ME62533
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------