Basic Information
| Provider Information | |||||||||
| NPI: | 1942660212 | ||||||||
| 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 320A | ||||||||
| City: | FERNANDINA BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 320344785 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9045579021 | ||||||||
| FaxNumber: | 9045579022 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/01/2016 | ||||||||
| LastUpdateDate: | 01/08/2019 | ||||||||
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| AuthorizedOfficialLastName: | WALL | ||||||||
| AuthorizedOfficialFirstName: | TIMOTHY | ||||||||
| AuthorizedOfficialMiddleName: | E | ||||||||
| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 9048587045 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | MS, ATC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | FL | N | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | 225100000X | FL | Y | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | CC4257 | 01 | FL | RR MEDICARE | OTHER |