MEDICARE: NORTH FLORIDA NEURODIAGNOSTICS, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy
1	2084N0400X	Neurology Physician
2	293D00000X	Physiological Laboratory
3	2084N0600X	Clinical Neurophysiology Physician

General Provider Information

NPI Number	:	1851916209
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NORTH FLORIDA NEURODIAGNOSTICS, LLC

Provider Business Mailing Address
First Line	:	426 SW COMMERCE DR STE 101
Second Line	:
City	:	LAKE CITY
State	:	FL
Zip	:	32025-1506
Country	:	US
Telephone Number	:	386-288-5311
Fax Number	:	386-288-0058

Provider Business Practice Location Address
First Line	:	426 SW COMMERCE DR STE 101
Second Line	:
City	:	LAKE CITY
State	:	FL
Zip	:	32025-1506
Country	:	US
Telephone Number	:	386-288-5311
Fax Number	:	386-288-0058

Authorized Official
Title or Position	:	OWNER
Name	:	ERNESTO ALONSO
Credential	:	M.D.
Telephone Number	:	386-288-5311

Provider Enumeration Date	:	06/11/2020
Last Update Date	:	06/24/2020

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