Basic Information
| Provider Information | |||||||||
| NPI: | 1134443583 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MEDICAL NEURODIAGNOSTICS & NEUROLOGY PL | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 17809 | ||||||||
| Address2: | |||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322457809 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9047235665 | ||||||||
| FaxNumber: | 9043380951 | ||||||||
| Practice Location | |||||||||
| Address1: | 1536 KINGSLEY AVE STE 116 | ||||||||
| Address2: | |||||||||
| City: | ORANGE PARK | ||||||||
| State: | FL | ||||||||
| PostalCode: | 320734525 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9047235665 | ||||||||
| FaxNumber: | 9043380951 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/15/2010 | ||||||||
| LastUpdateDate: | 07/22/2010 | ||||||||
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| AuthorizedOfficialLastName: | BAUGH | ||||||||
| AuthorizedOfficialFirstName: | RON | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 9047235665 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | PA | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | PA9101871 | FL | Y | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Specialist |
No ID Information.