MEDICARE: AMIR H. FATEMI, M.D., LLC

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	208600000X	Surgery Physician	ME34353	FL

General Provider Information

NPI Number	:	1013159110
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	AMIR H. FATEMI, M.D., LLC

Provider Business Mailing Address
First Line	:	6934 SAINT AUGUSTINE RD
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32217-2820
Country	:	US
Telephone Number	:	904-737-9393
Fax Number	:	904-737-9263

Provider Business Practice Location Address
First Line	:	6934 SAINT AUGUSTINE RD
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32217-2820
Country	:	US
Telephone Number	:	904-737-9393
Fax Number	:	904-737-9263

Authorized Official
Title or Position	:	OWNER
Name	:	DR. AMIR HOSSEIN FATEMI
Credential	:	M.D.
Telephone Number	:	904-737-9393

Provider Enumeration Date	:	04/03/2009
Last Update Date	:	04/03/2009

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