Basic Information
| Provider Information | |||||||||
| NPI: | 1427005131 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ST VINCENTS MEDICAL CENTER INC | ||||||||
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| OtherOrganizationName: | ST VINCENTS FAMILY MEDICINE CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2627 RIVERSIDE AVE | ||||||||
| Address2: | |||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322044712 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9043087372 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2627 RIVERSIDE AVE | ||||||||
| Address2: | |||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322044712 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9043087372 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/28/2006 | ||||||||
| LastUpdateDate: | 03/26/2010 | ||||||||
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| AuthorizedOfficialLastName: | MIYAMOTO | ||||||||
| AuthorizedOfficialFirstName: | GENE | ||||||||
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| AuthorizedOfficialTitleorPosition: | COO | ||||||||
| AuthorizedOfficialTelephone: | 9043081290 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | ST VINCENTS MEDICAL CENTER INC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP2300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Primary Care |
ID Information
| ID | Type | State | Issuer | Description | 057339600 | 05 | FL | MEDICAID | 99612 | 01 | FL | BCBS | OTHER |