Basic Information
| Provider Information | |||||||||
| NPI: | 1104817063 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | AUDEH | ||||||||
| FirstName: | JAMEEL | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 102222 | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303682222 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2392748200 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1970 GOLF ST | ||||||||
| Address2: | |||||||||
| City: | SARASOTA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 342366908 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9419571000 | ||||||||
| FaxNumber: | 9419512117 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/31/2005 | ||||||||
| LastUpdateDate: | 08/02/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/02/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RX0202X | ME54351 | FL | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Medical Oncology |
ID Information
| ID | Type | State | Issuer | Description | 104867300 | 05 | FL | MEDICAID |