Basic Information
| Provider Information | |||||||||
| NPI: | 1932146875 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | BEACHES NEUROLOGY CLINIC | ||||||||
| LastName: | |||||||||
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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: | 1370 13TH AVE S STE 215 | ||||||||
| Address2: | |||||||||
| City: | JACKSONVILLE BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322503206 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9042491041 | ||||||||
| FaxNumber: | 9042499764 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/31/2006 | ||||||||
| LastUpdateDate: | 11/20/2007 | ||||||||
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| AuthorizedOfficialLastName: | SNYDER | ||||||||
| AuthorizedOfficialFirstName: | THOMAS | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 9042491041 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | Y | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 45912 | 01 | FL | BCBS | OTHER |