MEDICARE: OCEANWAY MEDICAL CENTER, 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	207Q00000X	Family Medicine Physician		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

General Provider Information

NPI Number	:	1245255199
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	OCEANWAY MEDICAL CENTER, INC.

Provider Business Mailing Address
First Line	:	11513 N MAIN ST
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32218-4002
Country	:	US
Telephone Number	:	904-751-6200
Fax Number	:	904-751-1600

Provider Business Practice Location Address
First Line	:	11513 N MAIN ST
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32218-4002
Country	:	US
Telephone Number	:	904-751-6200
Fax Number	:	904-751-1600

Authorized Official
Title or Position	:	PRESIDENT
Name	:	JEANNE MICOLUCCI
Credential	:
Telephone Number	:	904-751-6200

Provider Enumeration Date	:	07/13/2006
Last Update Date	:	07/21/2022

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