Provider Demographics
NPI:1942660212
Name:JACKSONVILLE ORTHOPAEDIC INSTITUTE INC
Entity Type:Organization
Organization Name:JACKSONVILLE ORTHOPAEDIC INSTITUTE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:E
Authorized Official - Last Name:WALL
Authorized Official - Suffix:
Authorized Official - Credentials:MS, ATC
Authorized Official - Phone:904-858-7045
Mailing Address - Street 1:PO BOX 117345
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30368-7345
Mailing Address - Country:US
Mailing Address - Phone:904-346-3465
Mailing Address - Fax:904-858-6489
Practice Address - Street 1:1348 S 18TH ST
Practice Address - Street 2:SUITE 320A
Practice Address - City:FERNANDINA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32034-4785
Practice Address - Country:US
Practice Address - Phone:904-557-9021
Practice Address - Fax:904-557-9022
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-03-01
Last Update Date:2019-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL225100000X, 225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLCC4257OtherRR MEDICARE
FLCC4257OtherRR MEDICARE