Provider Demographics
NPI:1548805617
Name:IMPACT 13 MEDICAL, PLLC
Entity Type:Organization
Organization Name:IMPACT 13 MEDICAL, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:WIL
Authorized Official - Middle Name:E
Authorized Official - Last Name:GERMAIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:516-412-1608
Mailing Address - Street 1:10752 DEERWOOD PARK BLVD
Mailing Address - Street 2:SOUTH WATERVIEW II SUITE 100
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32256-8666
Mailing Address - Country:US
Mailing Address - Phone:904-755-1017
Mailing Address - Fax:646-774-0386
Practice Address - Street 1:10752 DEERWOOD PARK BLVD
Practice Address - Street 2:SOUTH WATERVIEW II SUITE 100
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32256
Practice Address - Country:US
Practice Address - Phone:904-755-1017
Practice Address - Fax:646-774-0386
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-11-13
Last Update Date:2019-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent PsychiatryGroup - Multi-Specialty
No2084P0805XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyGeriatric PsychiatryGroup - Multi-Specialty
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Multi-Specialty