Provider Demographics
NPI:1497723720
Name:JACKSONVILLE BEACH SURGERY CENTER, LLC
Entity Type:Organization
Organization Name:JACKSONVILLE BEACH SURGERY CENTER, LLC
Other - Org Name:JACKSONVILLE BEACH SURGERY CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SR VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:B
Authorized Official - Last Name:BALDOCK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-234-5900
Mailing Address - Street 1:3316 SOUTH THIRD STREET
Mailing Address - Street 2:STE 200
Mailing Address - City:JACKSONVILLE BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32250
Mailing Address - Country:US
Mailing Address - Phone:904-247-8181
Mailing Address - Fax:904-247-8101
Practice Address - Street 1:3316 SOUTH THIRD STREET
Practice Address - Street 2:STE 200
Practice Address - City:JACKSONVILLE BEACH
Practice Address - State:FL
Practice Address - Zip Code:32250
Practice Address - Country:US
Practice Address - Phone:904-247-8181
Practice Address - Fax:904-247-8101
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-11
Last Update Date:2016-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1120261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL070933600Medicaid
FL070933600Medicaid