Provider Demographics
NPI:1609931229
Name:THE SURGERY CENTER OF JACKSONVILLE LLC
Entity Type:Organization
Organization Name:THE SURGERY CENTER OF JACKSONVILLE LLC
Other - Org Name:CENTERONE SURGERY CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATIVE CLINICAL DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:BEVERLY
Authorized Official - Middle Name:J
Authorized Official - Last Name:TEAGUE
Authorized Official - Suffix:
Authorized Official - Credentials:RN CNOR LHRM
Authorized Official - Phone:904-652-2328
Mailing Address - Street 1:10475 CENTURION PKWY N
Mailing Address - Street 2:SUITE 101
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32256-5003
Mailing Address - Country:US
Mailing Address - Phone:904-652-2328
Mailing Address - Fax:
Practice Address - Street 1:10475 CENTURION PKWY N
Practice Address - Street 2:SUITE 101
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32256-5003
Practice Address - Country:US
Practice Address - Phone:904-652-2328
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-26
Last Update Date:2012-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLF1494Medicare UPIN