Provider Demographics
NPI:1679226690
Name:ST VINCENTS AMBULATORY CARE INC
Entity Type:Organization
Organization Name:ST VINCENTS AMBULATORY CARE INC
Other - Org Name:ASCENSION ST VINCENT'S MEDICAL GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ENROLLMENT MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MIRANDA
Authorized Official - Middle Name:
Authorized Official - Last Name:HEMM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:904-450-6004
Mailing Address - Street 1:4500 SAILSBURY RD STE 210
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32216
Mailing Address - Country:US
Mailing Address - Phone:904-308-6169
Mailing Address - Fax:904-308-4085
Practice Address - Street 1:425 N LEE ST STE 101
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32204-1128
Practice Address - Country:US
Practice Address - Phone:904-450-8762
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ST VINCENTS AMBULATORY CARE INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2022-01-31
Last Update Date:2022-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL276587086Medicaid