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General NPI Number Information
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NPI Number | 1700099017
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Entity Type | Organization
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Legal Business Name | SOUTHEASTERN NEUROSCIENCE INSTITUTE PA
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Dates
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Enumeration Date | 05/07/2007
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Last Update Date | 05/20/2008
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Provider Practice Location Address
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Address Line | 3728 PHILLIPS HWY SUITE 31
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City | JACKSONVILLE
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State | FL
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Zip | 32207-9300
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Country | US
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Telephone | 904-346-0707
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Fax | 904-396-4300
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Provider Business Mailing Address
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Address Line | 3728 PHILLIPS HWY SUITE 32
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City | JACKSONVILLE
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State | FL
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Zip | 32207-9300
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Country | US
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Telephone | 904-346-0707
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Fax | 904-396-4300
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Authorized Official
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Title or Position | CEO, NEUROLOGIST
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Name | DR. JACOB GREEN
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Credential | MD, PH.D
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Telephone | 904-346-0707
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number | ME 59265
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License Number State | FL
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Taxonomy #2
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number | ME45606
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License Number State | FL
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Taxonomy #3
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number | ME0013636
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License Number State | FL
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