=====================================================
General NPI Number Information
=====================================================
NPI Number | 1386766616
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BETTY ANNE MINCEY MD PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/06/2007
-----------------------------------------------------
Last Update Date | 05/04/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2370 3RD ST S SUITE 1
-----------------------------------------------------
City | JACKSONVILLE BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32250-4023
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-241-8069
-----------------------------------------------------
Fax | 904-241-8071
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2370 3RD ST S SUITE 1
-----------------------------------------------------
City | JACKSONVILLE BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32250-4023
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-241-8069
-----------------------------------------------------
Fax | 904-241-8071
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | SHARE HOLDER
-----------------------------------------------------
Name | DR. BETTY ANNE MINCEY
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 904-241-8069
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number | ME0071603
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------