Provider Demographics
NPI:1750444907
Name:RANALLI, NATHAN (MD)
Entity Type:Individual
Prefix:
First Name:NATHAN
Middle Name:
Last Name:RANALLI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 44008
Mailing Address - Street 2:PROVIDER ENROLLMENT
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32231-4008
Mailing Address - Country:US
Mailing Address - Phone:904-244-3660
Mailing Address - Fax:904-244-3425
Practice Address - Street 1:836 PRUDENTIAL DR
Practice Address - Street 2:SUITE 1205
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32207-8334
Practice Address - Country:US
Practice Address - Phone:904-633-0780
Practice Address - Fax:904-633-0783
Is Sole Proprietor?:No
Enumeration Date:2006-12-19
Last Update Date:2012-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD429742207T00000X
MO2011006604207T00000X
FLME112245207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003124430AMedicaid
FL005789500Medicaid
FL14K65OtherBCBS
FLGD664ZMedicare PIN