MEDICARE: JACKSONVILLE INTERNAL MEDICINE

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207R00000X	Internal Medicine Physician	25404	AL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	01D1017203	OTHER	AL	CLIA

General Provider Information

NPI Number	:	1013093152
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	JACKSONVILLE INTERNAL MEDICINE

Provider Business Mailing Address
First Line	:	PO BOX 550
Second Line	:
City	:	JACKSONVILLE
State	:	AL
Zip	:	36265-0550
Country	:	US
Telephone Number	:	256-343-1800
Fax Number	:	256-365-1046

Provider Business Practice Location Address
First Line	:	430 GEORGE WALLACE DR # 246
Second Line	:
City	:	GADSDEN
State	:	AL
Zip	:	35903-2280
Country	:	US
Telephone Number	:	256-343-1800
Fax Number	:	256-365-1046

Authorized Official
Title or Position	:	OWNER
Name	:	DR. REY GAVINO
Credential	:
Telephone Number	:	256-343-1800

Provider Enumeration Date	:	10/31/2006
Last Update Date	:	07/27/2023

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Directions to “JACKSONVILLE INTERNAL MEDICINE ” Practice Location

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