MEDICARE: CHILDREN'S MEDICAL GROUP PA

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	174400000X	Specialist

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	00149	OTHER	FL	BCBS

General Provider Information

NPI Number	:	1932180452
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CHILDREN'S MEDICAL GROUP PA

Provider Business Mailing Address
First Line	:	4131 UNIVERSITY BLVD S
Second Line	:	16
City	:	JACKSONVILLE
State	:	FL
Zip	:	32216-4326
Country	:	US
Telephone Number	:	907-733-7408
Fax Number	:	904-733-7668

Provider Business Practice Location Address
First Line	:	4131 UNIVERSITY BLVD S
Second Line	:	16
City	:	JACKSONVILLE
State	:	FL
Zip	:	32216-4326
Country	:	US
Telephone Number	:	907-733-7408
Fax Number	:	904-733-7668

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. DALE FRANKLIN ZIMMERMAN
Credential	:	MD
Telephone Number	:	907-268-6725

Provider Enumeration Date	:	11/10/2005
Last Update Date	:	08/22/2020

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Directions to “CHILDREN'S MEDICAL GROUP PA ” Practice Location

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