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NPI Code Detail

MEDICARE: NORTH FLORIDA MEDICAL CLINIC INC

MEDICARE: NORTH FLORIDA MEDICAL CLINIC INC
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
1207R00000XInternal Medicine PhysicianME43785FL

Medicare Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
3DD6503OTHERFLRAILROAD MEDICARE

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
194954OTHERFLBCBS
21639126907OTHERNPI

General Provider Information

NPI Number : 1639126907
Entity Type Code : Organization
Provider Name (Legal Business Name) : NORTH FLORIDA MEDICAL CLINIC INC
Provider Business Mailing Address
First Line : PO BOX 17809
Second Line :
City : JACKSONVILLE
State : FL
Zip : 32245-7809
Country : US
Telephone Number : 904-723-0015
Fax Number : 904-338-0951
Provider Business Practice Location Address
First Line : 1361 13TH AVE S STE 150
Second Line :
City : JACKSONVILLE BEACH
State : FL
Zip : 32250-3235
Country : US
Telephone Number : 904-242-7177
Fax Number : 904-242-7162
Authorized Official
Title or Position : PRESIDENT
Name : HOLTHAUS KEVIN
Credential : MD
Telephone Number : 904-242-7177
Provider Enumeration Date : 05/30/2006
Last Update Date : 01/24/2012

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Directions to “NORTH FLORIDA MEDICAL CLINIC INC ” Practice Location

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