Provider Demographics
NPI:1851333108
Name:MEMORIAL FAMILY PRACTICE ASSOCIATES LLC
Entity Type:Organization
Organization Name:MEMORIAL FAMILY PRACTICE ASSOCIATES LLC
Other - Org Name:JACKSONVILLE FAMILY PRACTICE ASSOCIATES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VP
Authorized Official - Prefix:
Authorized Official - First Name:MICKEY
Authorized Official - Middle Name:
Authorized Official - Last Name:PICKLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:904-725-6544
Mailing Address - Street 1:1731 UNIVERSITY BLVD S
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32216-8928
Mailing Address - Country:US
Mailing Address - Phone:904-725-6544
Mailing Address - Fax:904-721-5711
Practice Address - Street 1:1731 UNIVERSITY BLVD S
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32216-8928
Practice Address - Country:US
Practice Address - Phone:904-725-6544
Practice Address - Fax:904-721-5711
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-12
Last Update Date:2008-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLK9462Medicare PIN
DE7890Medicare PIN