MEDICARE: JACKSONVILLE ORTHOPAEDIC INSTITUTE INC

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	2255A2300X	Athletic Trainer	AL351	FL
2	225X00000X	Occupational Therapist
3	225100000X	Physical Therapist

General Provider Information

NPI Number	:	1205984762
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	JACKSONVILLE ORTHOPAEDIC INSTITUTE INC

Provider Business Mailing Address
First Line	:	PO BOX 117345
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30368-7345
Country	:	US
Telephone Number	:	904-346-3465
Fax Number	:	904-858-6489

Provider Business Practice Location Address
First Line	:	5393 ROOSEVELT BLVD
Second Line	:	SUITE 17
City	:	JACKSONVILLE
State	:	FL
Zip	:	32210-8448
Country	:	US
Telephone Number	:	904-389-8570
Fax Number	:	904-389-8599

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	MR. TIMOTHY EDWIN WALL
Credential	:	MS, ATC
Telephone Number	:	904-858-7045

Provider Enumeration Date	:	01/08/2007
Last Update Date	:	01/08/2019

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