=====================================================
General NPI Number Information
=====================================================
NPI Number | 1568425205
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | RADWAN SABBAGH M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/11/2006
-----------------------------------------------------
Last Update Date | 01/02/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5150-9 TIMUQUANA RD.
-----------------------------------------------------
City | JACKSONVILLE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32210
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-253-1120
-----------------------------------------------------
Fax | 904-253-2514
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 900 UNIVERSITY BLVD. NORTH MC 75
-----------------------------------------------------
City | JACKSONVILLE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32211
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-253-2062
-----------------------------------------------------
Fax | 904-253-1942
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208000000X
-----------------------------------------------------
Taxonomy Name | Pediatrics Physician
-----------------------------------------------------
License Number | ME66355
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 2080P0207X
-----------------------------------------------------
Taxonomy Name | Pediatric Hematology & Oncology Physician
-----------------------------------------------------
License Number | ME6635
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 2080P0207X
-----------------------------------------------------
Taxonomy Name | Pediatric Hematology & Oncology Physician
-----------------------------------------------------
License Number | ME66355
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------