=====================================================
General NPI Number Information
=====================================================
NPI Number | 1952771602
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ANDREWS SURGERY CENTER AT JACKSONVILLE MEDPLEX LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/06/2015
-----------------------------------------------------
Last Update Date | 10/06/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9726 TOUCHTON ROAD
-----------------------------------------------------
City | JACKSONVILLE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32246-8227
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 407-342-5842
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3241 HIDDEN LAKE DR
-----------------------------------------------------
City | WINTER GARDEN
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34787-5427
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 407-342-5842
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGER
-----------------------------------------------------
Name | DR. DONALD JEFF SAPP
-----------------------------------------------------
Credential | PH.D.
-----------------------------------------------------
Telephone | 407-342-5842
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QA1903X
-----------------------------------------------------
Taxonomy Name | Ambulatory Surgical Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------