Basic Information
| Provider Information | |||||||||
| NPI: | 1083778468 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BREMER | ||||||||
| FirstName: | NICHOLAS | ||||||||
| MiddleName: | JOHN | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5191 FIRST COAST TECH PKWY | ||||||||
| Address2: | 3RD FLOOR | ||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 32224 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9042233321 | ||||||||
| FaxNumber: | 9042232169 | ||||||||
| Practice Location | |||||||||
| Address1: | 1699 S 14TH ST STE 16 | ||||||||
| Address2: | |||||||||
| City: | FERNANDINA BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 320341965 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9042233321 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/20/2006 | ||||||||
| LastUpdateDate: | 09/29/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/27/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208VP0000X | ME126043 | FL | Y | Allopathic & Osteopathic Physicians | Pain Medicine | Pain Medicine |
ID Information
| ID | Type | State | Issuer | Description | 108108900 | 05 | FL | MEDICAID |