MEDICARE: NORTHEAST FLORIDA JOINT PRESERVATION AND CARTILAGE RESTORATION CENTER

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	207X00000X	Orthopaedic Surgery Physician	ME112470	FL

General Provider Information

NPI Number	:	1457772139
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NORTHEAST FLORIDA JOINT PRESERVATION AND CARTILAGE RESTORATION CENTER

Provider Business Mailing Address
First Line	:	PO BOX 65201
Second Line	:
City	:	ORANGE PARK
State	:	FL
Zip	:	32065-0004
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	9560 CROSSHILL BLVD
Second Line	:	SUITE 110
City	:	JACKSONVILLE
State	:	FL
Zip	:	32222-5850
Country	:	US
Telephone Number	:	904-308-7792
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	STEVEN LALLISS
Credential	:	MD
Telephone Number	:	904-308-7792

Provider Enumeration Date	:	12/23/2013
Last Update Date	:	12/23/2013

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