Basic Information
| Provider Information | |||||||||
| NPI: | 1871535492 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | JACKSONVILLE HOSPITALISTS PA | ||||||||
| LastName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | CISCA PULMONARY AND CRITICAL CARE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8773 PERIMETER PARK CT | ||||||||
| Address2: | |||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322161165 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9044933390 | ||||||||
| FaxNumber: | 9044933395 | ||||||||
| Practice Location | |||||||||
| Address1: | 8773 PERIMETER PARK CT | ||||||||
| Address2: | |||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322161165 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9044933390 | ||||||||
| FaxNumber: | 9044933395 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/11/2006 | ||||||||
| LastUpdateDate: | 07/01/2019 | ||||||||
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| AuthorizedOfficialLastName: | MURDAUGH | ||||||||
| AuthorizedOfficialFirstName: | INDIA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | COO | ||||||||
| AuthorizedOfficialTelephone: | 9044933390 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | 207RC0200X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Critical Care Medicine | 207RP1001X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Pulmonary Disease | 208M00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Hospitalist |
ID Information
| ID | Type | State | Issuer | Description | 869827862A | 05 | GA | MEDICAID | 261029900 | 05 | FL | MEDICAID |