Provider Demographics
NPI:1760695852
Name:ST. JOHNS BLUFF FAMILY PRACTICE
Entity Type:Organization
Organization Name:ST. JOHNS BLUFF FAMILY PRACTICE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:MERRIANNE
Authorized Official - Middle Name:RENEE
Authorized Official - Last Name:RUST
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:904-564-4343
Mailing Address - Street 1:3690 SAINT JOHNS BLUFF RD S
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32224-2616
Mailing Address - Country:US
Mailing Address - Phone:904-564-4343
Mailing Address - Fax:904-224-7051
Practice Address - Street 1:3690 SAINT JOHNS BLUFF RD S
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32224-2616
Practice Address - Country:US
Practice Address - Phone:904-564-4343
Practice Address - Fax:904-224-7051
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-07
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME060414207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLCK5826Medicare ID - Type UnspecifiedRAIL ROAD MEDICARE GROUP
FL34223Medicare ID - Type UnspecifiedMEDICARE GROUP