MEDICARE: DR. GRANT TYLER WHITTAKER M.D.

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	MD 30868	AL
2	207R00000X	Internal Medicine Physician	ME 105816	FL
3	207RG0100X	Gastroenterology Physician	ME105816	FL

General Provider Information

NPI Number	:	1073710992
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. GRANT TYLER WHITTAKER M.D.

Provider Business Mailing Address
First Line	:	4800 BELFORT RD
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32256-6004
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1348 SOUTH 18TH STREET
Second Line	:	SUITE 100
City	:	FERNANDINA BEACH
State	:	FL
Zip	:	32034-4755
Country	:	US
Telephone Number	:	904-261-0879
Fax Number	:	904-277-7054

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/03/2007
Last Update Date	:	08/27/2014

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