Provider Demographics
NPI:1861991937
Name:JACKSONVILLE LUNG CLINIC LLC
Entity type:Organization
Organization Name:JACKSONVILLE LUNG CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CHAD
Authorized Official - Middle Name:
Authorized Official - Last Name:PEW
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:307-262-9410
Mailing Address - Street 1:7500 RIALTO BLVD
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78735-8531
Mailing Address - Country:US
Mailing Address - Phone:512-730-3060
Mailing Address - Fax:
Practice Address - Street 1:1350 13TH AVE S
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE BEACH
Practice Address - State:FL
Practice Address - Zip Code:32250-3203
Practice Address - Country:US
Practice Address - Phone:904-627-2900
Practice Address - Fax:904-253-3098
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-02-05
Last Update Date:2025-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care MedicineGroup - Multi-Specialty
No207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary DiseaseGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL022274400Medicaid