Provider Demographics
NPI:1073604914
Name:SHANDS JACKSONVILLE MEDICAL CENTER INC
Entity Type:Organization
Organization Name:SHANDS JACKSONVILLE MEDICAL CENTER INC
Other - Org Name:SHANDS JACKSONVILLE PLAZA PHARMACY
Other - Org Type:Doing Business As
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:904-244-8675
Mailing Address - Fax:904-244-4027
Practice Address - Street 1:580 W 8TH ST # 2
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32209-6533
Practice Address - Country:US
Practice Address - Phone:904-244-9162
Practice Address - Fax:904-244-9166
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SHANDS JACKSONVILLE MEDICAL CENTER, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-09-27
Last Update Date:2009-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPH21850332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL031291601Medicaid
FL0813240002Medicare NSC