Provider Demographics
NPI:1790772317
Name:MAYO CLINIC JACKSONVILLE
Entity Type:Organization
Organization Name:MAYO CLINIC JACKSONVILLE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:ALICE
Authorized Official - Middle Name:
Authorized Official - Last Name:RIGDON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:904-953-0577
Mailing Address - Street 1:4500 SAN PABLO ROAD
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32224-1865
Mailing Address - Country:US
Mailing Address - Phone:904-953-7355
Mailing Address - Fax:904-953-1768
Practice Address - Street 1:4500 SAN PABLO ROAD
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32224-1865
Practice Address - Country:US
Practice Address - Phone:904-953-1768
Practice Address - Fax:904-953-1768
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-29
Last Update Date:2021-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL064350500Medicaid
FL064350501Medicaid
FL064350503Medicaid
FL064350500Medicaid
3972130001Medicare NSC