Basic Information
| Provider Information | |||||||||
| NPI: | 1609319607 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | JACKSONVILLE ORTHOPAEDIC INSTITUTE INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 117345 | ||||||||
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| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303687345 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9043463465 | ||||||||
| FaxNumber: | 9048586489 | ||||||||
| Practice Location | |||||||||
| Address1: | 1348 S 18TH ST | ||||||||
| Address2: | SUITE 320B | ||||||||
| City: | FERNANDINA BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 320344785 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9042618787 | ||||||||
| FaxNumber: | 9042619653 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/22/2016 | ||||||||
| LastUpdateDate: | 01/24/2019 | ||||||||
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| AuthorizedOfficialLastName: | RICCHINI | ||||||||
| AuthorizedOfficialFirstName: | JOHN | ||||||||
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| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 9043463465 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | FL | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 003151000 | 05 | FL | MEDICAID | CC4257 | 01 | FL | RR MEDICARE | OTHER |