MEDICARE: SAMUEL J. FERN DO

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	OS6092	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	:	1437136074
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SAMUEL J. FERN DO

Provider Business Mailing Address
First Line	:	PO BOX 44004
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32231-4004
Country	:	US
Telephone Number	:	904-202-1032
Fax Number	:	904-249-0347

Provider Business Practice Location Address
First Line	:	900 BEACH BLVD
Second Line	:	CREDENTIALING DEPARTMENT
City	:	JACKSONVILLE BEACH
State	:	FL
Zip	:	32250-4368
Country	:	US
Telephone Number	:	904-249-0335
Fax Number	:	904-249-0347

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

Provider Enumeration Date	:	12/26/2005
Last Update Date	:	11/25/2015

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