Basic Information
| Provider Information | |||||||||
| NPI: | 1750444907 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | RANALLI | ||||||||
| FirstName: | NATHAN | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 44008 | ||||||||
| Address2: | PROVIDER ENROLLMENT | ||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322314008 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9042443660 | ||||||||
| FaxNumber: | 9042443425 | ||||||||
| Practice Location | |||||||||
| Address1: | 836 PRUDENTIAL DR | ||||||||
| Address2: | SUITE 1205 | ||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322078334 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9046330780 | ||||||||
| FaxNumber: | 9046330783 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/19/2006 | ||||||||
| LastUpdateDate: | 07/31/2012 | ||||||||
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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 | 207T00000X | MD429742 | PA | N | Allopathic & Osteopathic Physicians | Neurological Surgery | 207T00000X | 2011006604 | MO | N | Allopathic & Osteopathic Physicians | Neurological Surgery | 207T00000X | ME112245 | FL | Y | Allopathic & Osteopathic Physicians | Neurological Surgery |
ID Information
| ID | Type | State | Issuer | Description | 003124430A | 05 | GA | MEDICAID | 005789500 | 05 | FL | MEDICAID | 14K65 | 01 | FL | BCBS | OTHER |