MEDICARE: SACRED HEART MEDICAL GROUP

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

General Provider Information

NPI Number	:	1841960135
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SACRED HEART MEDICAL GROUP

Provider Business Mailing Address
First Line	:	4205 BELFORT RD STE 4015
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32216-3623
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	11111 PANAMA CITY BEACH PKWY STE 3
Second Line	:
City	:	PANAMA CITY BEACH
State	:	FL
Zip	:	32407-2448
Country	:	US
Telephone Number	:	850-267-1603
Fax Number	:

Authorized Official
Title or Position	:	DIRECTOR
Name	:	JEAN VALLIER
Credential	:
Telephone Number	:	850-267-1603

Provider Enumeration Date	:	09/17/2021
Last Update Date	:	09/17/2021

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