Provider Demographics
NPI:1144302761
Name:SHANDS JACKSONVILLE MEDICAL CENTER INC
Entity type:Organization
Organization Name:SHANDS JACKSONVILLE MEDICAL CENTER INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:VP OF FINANCE AND TREASURER
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:E
Authorized Official - Last Name:GLEASON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:904-244-8675
Mailing Address - Street 1:655 W 8TH ST
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32209-6511
Mailing Address - Country:US
Mailing Address - Phone:904-244-9875
Mailing Address - Fax:904-244-9861
Practice Address - Street 1:655 W 8TH ST
Practice Address - Street 2:1ST FLOOR PAVILION NORTH, 1900 BOULEVARD ST.
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32209-6511
Practice Address - Country:US
Practice Address - Phone:904-244-9875
Practice Address - Fax:904-244-9861
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SHANDS JACKSONVILLE MEDICAL CENTER, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-10-20
Last Update Date:2024-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL800001707291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL10-HL03Medicare ID - Type Unspecified