=====================================================
General NPI Number Information
=====================================================
NPI Number | 1285938936
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MEDICAL SPECIALISTS OF NORTHEAST FLORIDA PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/10/2011
-----------------------------------------------------
Last Update Date | 09/15/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6428 BEACH BLVD STE 1A
-----------------------------------------------------
City | JACKSONVILLE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32216-2813
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-342-0816
-----------------------------------------------------
Fax | 904-342-0553
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6428 BEACH BLVD STE 1A
-----------------------------------------------------
City | JACKSONVILLE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32216-2813
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-475-2039
-----------------------------------------------------
Fax | 904-330-0668
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MEMBER
-----------------------------------------------------
Name | MADHU SHARAM
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 904-718-3184
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------