Basic Information
| Provider Information | |||||||||
| NPI: | 1346413606 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SCIMEME | ||||||||
| FirstName: | JASON | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 44008 | ||||||||
| Address2: | UFJP-PROVIDER ENROLLMENT | ||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322314008 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9042443660 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 800 PRUDENTIAL DR | ||||||||
| Address2: | |||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322078202 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9042028758 | ||||||||
| FaxNumber: | 9043069884 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/08/2008 | ||||||||
| LastUpdateDate: | 11/16/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 243668 | NY | N | Allopathic & Osteopathic Physicians | Pediatrics | 208000000X | ME110705 | FL | N | Allopathic & Osteopathic Physicians | Pediatrics | 2080P0203X | ME110705 | FL | Y | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Critical Care Medicine |
ID Information
| ID | Type | State | Issuer | Description | 003836800 | 05 | FL | MEDICAID | 003111437A | 05 | GA | MEDICAID | 14F39 | 01 | FL | BCBSFL | OTHER |