MEDICARE: BURTON H. MENDEL PA

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	363A00000X	Physician Assistant	PA 1919	FL

General Provider Information

NPI Number	:	1306861240
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BURTON H. MENDEL PA

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	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/13/2006
Last Update Date	:	07/09/2007

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