Provider Demographics
NPI:1679868467
Name:MOUNT GILEAD
Entity Type:Organization
Organization Name:MOUNT GILEAD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:CAREY
Authorized Official - Last Name:MERRITT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:904-296-3113
Mailing Address - Street 1:6817 SOUTHPOINT PKWY
Mailing Address - Street 2:SUITE 304
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32216-6282
Mailing Address - Country:US
Mailing Address - Phone:904-296-3113
Mailing Address - Fax:904-296-3144
Practice Address - Street 1:6817 SOUTHPOINT PKWY
Practice Address - Street 2:SUITE 304
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32216-6282
Practice Address - Country:US
Practice Address - Phone:904-296-3113
Practice Address - Fax:904-296-3144
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-06-09
Last Update Date:2011-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL603914261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL603914OtherSTATE OF FLORIDA