=====================================================
General NPI Number Information
=====================================================
NPI Number | 1326017419
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NAVAL HOSPITAL JACKSONVILLE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/14/2006
-----------------------------------------------------
Last Update Date | 08/13/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2080 CHILD ST NAVAL HOSPITAL JACKSONVILLE- INTERNAL MEDICINE CLINIC
-----------------------------------------------------
City | JACKSONVILLE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32214-5005
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-542-7910
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1754 RUSTLING DR
-----------------------------------------------------
City | ORANGE PARK
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32003-8634
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-215-9149
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | STAFF PHYSICIAN
-----------------------------------------------------
Name | DR. MICHELLE MARIE PERELLO
-----------------------------------------------------
Credential | DO
-----------------------------------------------------
Telephone | 904-542-7911
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 286500000X
-----------------------------------------------------
Taxonomy Name | Military Hospital
-----------------------------------------------------
License Number | 20A 7245
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------