Provider Demographics
NPI:1598869844
Name:MEMORIAL FAMILY PRACTICE ASSOCIATES, LLC
Entity Type:Organization
Organization Name:MEMORIAL FAMILY PRACTICE ASSOCIATES, LLC
Other - Org Name:MEMORIAL FAMILY PRACTICE ASSOCIATES
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:A
Authorized Official - Last Name:FAILE
Authorized Official - Suffix:III
Authorized Official - Credentials:
Authorized Official - Phone:843-956-7923
Mailing Address - Street 1:1731 UNIVERSITY BLVD S
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32216-8928
Mailing Address - Country:US
Mailing Address - Phone:904-725-0200
Mailing Address - Fax:904-721-5711
Practice Address - Street 1:1731 UNIVERSITY BLVD S
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32216-8928
Practice Address - Country:US
Practice Address - Phone:904-725-0200
Practice Address - Fax:904-721-5711
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MEMORIAL FAMILY PRACTICE ASSOCIATES, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-09-08
Last Update Date:2023-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0010521207Q00000X
207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLK9462Medicare PIN