Basic Information
Provider Information | |||||||||
NPI: | 1396926747 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | ST LUKES - ST VINCENTS HEALTHCARE | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | ASCENSION ST. VINCENT'S SOUTHSIDE | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 4205 BELFORT RD | ||||||||
Address2: | JAB # 4020 | ||||||||
City: | JACKSONVILLE | ||||||||
State: | FL | ||||||||
PostalCode: | 32216 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9044506020 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 4201 BELFORT RD | ||||||||
Address2: |   | ||||||||
City: | JACKSONVILLE | ||||||||
State: | FL | ||||||||
PostalCode: | 322161431 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9042963700 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/14/2007 | ||||||||
LastUpdateDate: | 04/28/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | KRAFT | ||||||||
AuthorizedOfficialFirstName: | JEREMY | ||||||||
AuthorizedOfficialMiddleName: | DEAN | ||||||||
AuthorizedOfficialTitleorPosition: | DIRECTOR- NET REVENUE | ||||||||
AuthorizedOfficialTelephone: | 9044506020 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 04/28/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282N00000X |   |   | Y |   | Hospitals | General Acute Care Hospital |   |
No ID Information.