Provider Demographics
NPI:1619341039
Name:JACKSONVILLE MEDICAL GROUP, LLC
Entity Type:Organization
Organization Name:JACKSONVILLE MEDICAL GROUP, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SAMAN
Authorized Official - Middle Name:
Authorized Official - Last Name:SOLEYMANI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:904-962-7396
Mailing Address - Street 1:396 N LOMBARDY LOOP
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32259-5266
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1409 KINGSLEY AVE
Practice Address - Street 2:SUITE 9G
Practice Address - City:ORANGE PARK
Practice Address - State:FL
Practice Address - Zip Code:32073-4537
Practice Address - Country:US
Practice Address - Phone:904-637-0037
Practice Address - Fax:904-639-6017
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-11-23
Last Update Date:2016-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ZZME88018207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLIP452AMedicare PIN