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General NPI Number Information
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NPI Number | 1639126907
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Entity Type | Organization
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Legal Business Name | NORTH FLORIDA MEDICAL CLINIC INC
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Dates
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Enumeration Date | 05/30/2006
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Last Update Date | 01/24/2012
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Provider Practice Location Address
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Address Line | 1361 13TH AVE S STE 150
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City | JACKSONVILLE BEACH
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State | FL
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Zip | 32250-3235
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Country | US
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Telephone | 904-242-7177
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Fax | 904-242-7162
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Provider Business Mailing Address
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Address Line | PO BOX 17809
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City | JACKSONVILLE
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State | FL
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Zip | 32245-7809
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Country | US
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Telephone | 904-723-0015
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Fax | 904-338-0951
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Authorized Official
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Title or Position | PRESIDENT
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Name | HOLTHAUS KEVIN
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Credential | MD
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Telephone | 904-242-7177
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207R00000X
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Taxonomy Name | Internal Medicine Physician
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License Number | ME43785
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License Number State | FL
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