Provider Demographics
NPI:1609951938
Name:JACKSONVILLE MULTISPECIALTY GROUP, LLC
Entity Type:Organization
Organization Name:JACKSONVILLE MULTISPECIALTY GROUP, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:HERNAN
Authorized Official - Middle Name:ROBERT
Authorized Official - Last Name:CHANG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:904-399-1623
Mailing Address - Street 1:PO BOX 17577
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32245-7577
Mailing Address - Country:US
Mailing Address - Phone:904-399-1623
Mailing Address - Fax:904-399-1624
Practice Address - Street 1:3627 UNIVERSITY BLVD S STE 615
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32216-7401
Practice Address - Country:US
Practice Address - Phone:904-399-1623
Practice Address - Fax:904-399-1624
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-26
Last Update Date:2023-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL207Q00000X, 207R00000X, 207RI0200X, 208VP0014X, 208VP0014X, 207RI0200X
208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious DiseaseGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No208M00000XAllopathic & Osteopathic PhysiciansHospitalistGroup - Multi-Specialty
No208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL001151900Medicaid
FLQ0331Medicare PIN
FLH23987Medicare UPIN