MEDICARE: NEMOURS CHILDREN'S HEALTH, LONGWOOD, PRIMARY CARE

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	208000000X	Pediatrics Physician

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	:	1477122638
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NEMOURS CHILDREN'S HEALTH, LONGWOOD, PRIMARY CARE

Provider Business Mailing Address
First Line	:	10140 CENTURION PKWY N
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32256-0532
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	521 W SR 434 STE 101
Second Line	:
City	:	LONGWOOD
State	:	FL
Zip	:	32750-4952
Country	:	US
Telephone Number	:	407-237-9700
Fax Number	:

Authorized Official
Title or Position	:	EVP, OPERATIONS
Name	:	ROBERT BRIDGES
Credential	:
Telephone Number	:	904-697-4000

Provider Enumeration Date	:	06/22/2021
Last Update Date	:	06/22/2021

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