MEDICARE: JULINGTON CREEK PEDIATRICS

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	305R00000X	Preferred Provider Organization	NE74170	FL

General Provider Information

NPI Number	:	1891188173
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	JULINGTON CREEK PEDIATRICS

Provider Business Mailing Address
First Line	:	774 STATE ROAD 13 STE 6
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32259-3815
Country	:	US
Telephone Number	:	904-230-5437
Fax Number	:

Provider Business Practice Location Address
First Line	:	774 STATE ROAD 13 STE 6
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32259-3815
Country	:	US
Telephone Number	:	904-230-5437
Fax Number	:

Authorized Official
Title or Position	:	BILLING MANAGER
Name	:	LISA ANN BENEDICT
Credential	:
Telephone Number	:	904-230-5437

Provider Enumeration Date	:	03/11/2015
Last Update Date	:	03/11/2015

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