Provider Demographics
NPI:1326647504
Name:ORTHO ONE JACKSONVILLE
Entity Type:Organization
Organization Name:ORTHO ONE JACKSONVILLE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:
Authorized Official - Last Name:ROGERS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:904-619-3048
Mailing Address - Street 1:6100 KENNERLY RD STE 202
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32216-4379
Mailing Address - Country:US
Mailing Address - Phone:904-619-3048
Mailing Address - Fax:904-619-5753
Practice Address - Street 1:6100 KENNERLY RD STE 202
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32216-4379
Practice Address - Country:US
Practice Address - Phone:904-619-3048
Practice Address - Fax:904-619-5753
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-10-20
Last Update Date:2020-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports MedicineGroup - Multi-Specialty