Provider Demographics
NPI:1427005131
Name:ST VINCENTS MEDICAL CENTER INC
Entity Type:Organization
Organization Name:ST VINCENTS MEDICAL CENTER INC
Other - Org Name:ST VINCENTS FAMILY MEDICINE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:COO
Authorized Official - Prefix:
Authorized Official - First Name:GENE
Authorized Official - Middle Name:
Authorized Official - Last Name:MIYAMOTO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:904-308-1290
Mailing Address - Street 1:2627 RIVERSIDE AVE
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32204-4712
Mailing Address - Country:US
Mailing Address - Phone:904-308-7372
Mailing Address - Fax:
Practice Address - Street 1:2627 RIVERSIDE AVE
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32204-4712
Practice Address - Country:US
Practice Address - Phone:904-308-7372
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ST VINCENTS MEDICAL CENTER INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-05-28
Last Update Date:2010-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL057339600Medicaid
FL99612OtherBCBS
FL99612OtherBCBS
FL057339600Medicaid