MEDICARE: INTERCOASTAL HEALTH

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	261QH0100X	Health Service Clinic/Center

General Provider Information

NPI Number	:	1518775873
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	INTERCOASTAL HEALTH

Provider Business Mailing Address
First Line	:	4320 DEERWOOD LAKE PKWY STE 327
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32216-1177
Country	:	US
Telephone Number	:	904-799-2531
Fax Number	:	904-659-8558

Provider Business Practice Location Address
First Line	:	3874 SAN JOSE PARK DR STE 5
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32217-4660
Country	:	US
Telephone Number	:	904-799-2531
Fax Number	:	904-659-8558

Authorized Official
Title or Position	:	MANAGER
Name	:	PETER CHRISTOPHER MCDERMOTT
Credential	:	APRN
Telephone Number	:	904-799-2531

Provider Enumeration Date	:	12/19/2024
Last Update Date	:	02/16/2026

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Directions to “INTERCOASTAL HEALTH ” Practice Location

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