MEDICARE: JACKSONVILLE INTERNAL MEDICINE

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	207R00000X	Internal Medicine Physician	ME0043103	FL

General Provider Information

NPI Number	:	1962607739
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	JACKSONVILLE INTERNAL MEDICINE

Provider Business Mailing Address
First Line	:	6144 GAZEBO PARK PL S
Second Line	:	SUITE 102
City	:	JACKSONVILLE
State	:	FL
Zip	:	32257-1099
Country	:	US
Telephone Number	:	904-396-0454
Fax Number	:	904-346-3662

Provider Business Practice Location Address
First Line	:	6144 GAZEBO PARK PL S
Second Line	:	SUITE 102
City	:	JACKSONVILLE
State	:	FL
Zip	:	32257-1099
Country	:	US
Telephone Number	:	904-396-0454
Fax Number	:	904-346-3662

Authorized Official
Title or Position	:	OWNER
Name	:	MRS. ILENE S LEVENSON
Credential	:	MD
Telephone Number	:	904-396-0454

Provider Enumeration Date	:	06/20/2007
Last Update Date	:	08/22/2020

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