MEDICARE: MEMORIAL HEALTHCARE GROUP, 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
1	282E00000X	Long Term Care Hospital

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	044069	OTHER	FL	AVMED
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	Y34	OTHER	FL	BLUE CROSS/HOPT
4	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
5	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1851348429
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MEMORIAL HEALTHCARE GROUP, INC.

Provider Business Mailing Address
First Line	:	4901 RICHARD ST
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32207-7328
Country	:	US
Telephone Number	:	904-737-3120
Fax Number	:	904-730-5991

Provider Business Practice Location Address
First Line	:	4901 RICHARD ST
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32207-7328
Country	:	US
Telephone Number	:	904-737-3120
Fax Number	:	904-730-5991

Authorized Official
Title or Position	:	CFO
Name	:	BILLY WILCOX
Credential	:
Telephone Number	:	904-730-5756

Provider Enumeration Date	:	05/28/2006
Last Update Date	:	03/30/2022

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