Basic Information
| Provider Information | |||||||||
| NPI: | 1457326472 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HARGREAVES | ||||||||
| FirstName: | MICHELE | ||||||||
| MiddleName: | ST MARTIN | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | ST MARTIN | ||||||||
| OtherFirstName: | MICHELE | ||||||||
| OtherMiddleName: | BAUCHET | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 11945 SAN JOSE BLVD | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322231613 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9043961725 | ||||||||
| FaxNumber: | 9043991717 | ||||||||
| Practice Location | |||||||||
| Address1: | 4203 BELFORT RD | ||||||||
| Address2: | STE 340 | ||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322161409 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9048800911 | ||||||||
| FaxNumber: | 9048809388 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/22/2006 | ||||||||
| LastUpdateDate: | 11/07/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | MD425320 | PA | N | Other Service Providers | Specialist | 207Y00000X | ME98473 | FL | Y | Allopathic & Osteopathic Physicians | Otolaryngology | 207YX0901X | ME98473 | FL | N | Allopathic & Osteopathic Physicians | Otolaryngology | Otology & Neurotology |
ID Information
| ID | Type | State | Issuer | Description | 278642700 | 05 | FL | MEDICAID |