Provider Demographics
NPI:1629198544
Name:JACK M. MATHENY II, MD
Entity Type:Organization
Organization Name:JACK M. MATHENY II, MD
Other - Org Name:JACK M. MATHENY II, MD, RHC
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JACK
Authorized Official - Middle Name:MEADOWS
Authorized Official - Last Name:MATHENY
Authorized Official - Suffix:II
Authorized Official - Credentials:MD
Authorized Official - Phone:386-328-6746
Mailing Address - Street 1:700 ZEAGLER DR STE 10
Mailing Address - Street 2:
Mailing Address - City:PALATKA
Mailing Address - State:FL
Mailing Address - Zip Code:32177-3826
Mailing Address - Country:US
Mailing Address - Phone:386-328-6746
Mailing Address - Fax:386-328-7554
Practice Address - Street 1:700 ZEAGLER DR STE 10
Practice Address - Street 2:
Practice Address - City:PALATKA
Practice Address - State:FL
Practice Address - Zip Code:32177-3826
Practice Address - Country:US
Practice Address - Phone:386-328-6746
Practice Address - Fax:386-328-7554
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:JACK M MATHENY II MD
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-04-02
Last Update Date:2019-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0048571261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL372143401Medicaid
FL372143401Medicaid
FL39790Medicare PIN