MEDICARE: RUSSELL RAYMOND JAICKS 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	208600000X	Surgery Physician	ME113621	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1184727414
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RUSSELL RAYMOND JAICKS M.D.

Provider Business Mailing Address
First Line	:	720 W OAK ST
Second Line	:	STE 101
City	:	KISSIMMEE
State	:	FL
Zip	:	34741-4989
Country	:	US
Telephone Number	:	407-846-3166
Fax Number	:

Provider Business Practice Location Address
First Line	:	720 W OAK ST
Second Line	:	SUITE 101
City	:	KISSIMMEE
State	:	FL
Zip	:	34741-4989
Country	:	US
Telephone Number	:	407-846-3166
Fax Number	:

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

Provider Enumeration Date	:	09/05/2006
Last Update Date	:	04/18/2013

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