Basic Information
| Provider Information | |||||||||
| NPI: | 1558039834 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SACRED HEART MEDICAL GROUP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4205 BELFORT RD STE 4015 | ||||||||
| Address2: | |||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322163623 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 1299 US HIGHWAY 90 W STE 1 | ||||||||
| Address2: | |||||||||
| City: | DEFUNIAK SPRINGS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 324331400 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8504164970 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/01/2021 | ||||||||
| LastUpdateDate: | 09/01/2021 | ||||||||
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| AuthorizedOfficialLastName: | VALLIER | ||||||||
| AuthorizedOfficialFirstName: | JEAN | ||||||||
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| AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 8504164970 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 09/01/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RI0011X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Interventional Cardiology |
No ID Information.