Provider Demographics
NPI:1689942047
Name:JACK H SOLIMAN MD PA
Entity Type:Organization
Organization Name:JACK H SOLIMAN MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JACK
Authorized Official - Middle Name:H
Authorized Official - Last Name:SOLIMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD PA
Authorized Official - Phone:386-328-1117
Mailing Address - Street 1:6100 SAINT JOHNS AVE
Mailing Address - Street 2:SUITE 1
Mailing Address - City:PALATKA
Mailing Address - State:FL
Mailing Address - Zip Code:32177-3844
Mailing Address - Country:US
Mailing Address - Phone:386-328-1117
Mailing Address - Fax:386-328-0533
Practice Address - Street 1:6100 SAINT JOHNS AVE
Practice Address - Street 2:SUITE 1
Practice Address - City:PALATKA
Practice Address - State:FL
Practice Address - Zip Code:32177-3844
Practice Address - Country:US
Practice Address - Phone:386-328-1117
Practice Address - Fax:386-328-0533
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-12-13
Last Update Date:2011-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0064892302F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302F00000XManaged Care OrganizationsExclusive Provider Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLF30225Medicare UPIN