Provider Demographics
NPI:1750537445
Name:MEDEX CLINIC, LLC
Entity type:Organization
Organization Name:MEDEX CLINIC, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT-MGRM
Authorized Official - Prefix:DR
Authorized Official - First Name:ASIM
Authorized Official - Middle Name:
Authorized Official - Last Name:NOUMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:904-388-3229
Mailing Address - Street 1:1395 CASSAT AVE STE 3
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32205-9615
Mailing Address - Country:US
Mailing Address - Phone:904-388-3229
Mailing Address - Fax:904-207-7321
Practice Address - Street 1:865 CASSAT AVE
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32205-4856
Practice Address - Country:US
Practice Address - Phone:904-388-3229
Practice Address - Fax:904-388-8611
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-13
Last Update Date:2014-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME100337261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1427237916Medicare PIN