Provider Demographics
NPI:1710934930
Name:JACKSONVILLE NEUROLOGICAL CLINIC, P.A.
Entity Type:Organization
Organization Name:JACKSONVILLE NEUROLOGICAL CLINIC, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DENNIS
Authorized Official - Middle Name:
Authorized Official - Last Name:DEWEY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:904-276-2220
Mailing Address - Street 1:PO BOX 17809
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32245-7809
Mailing Address - Country:US
Mailing Address - Phone:904-723-0015
Mailing Address - Fax:904-338-0951
Practice Address - Street 1:1895 KINGSLEY AVE STE 805
Practice Address - Street 2:
Practice Address - City:ORANGE PARK
Practice Address - State:FL
Practice Address - Zip Code:32073-4410
Practice Address - Country:US
Practice Address - Phone:904-276-2220
Practice Address - Fax:904-276-2578
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-31
Last Update Date:2007-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLCF1455OtherRAILROAD MEDICARE
FL00506OtherBCBS
FLCF1455OtherRAILROAD MEDICARE