Provider Demographics
NPI:1790879732
Name:ST LUKES - ST VINCENTS HEALTHCARE
Entity type:Organization
Organization Name:ST LUKES - ST VINCENTS HEALTHCARE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CHIEF OPERATING OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:COBA
Authorized Official - Middle Name:SUSAN
Authorized Official - Last Name:CORNEJO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:803-463-5837
Mailing Address - Street 1:1 SHIRCLIFF WAY
Mailing Address - Street 2:STE 1734
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32204
Mailing Address - Country:US
Mailing Address - Phone:904-308-7515
Mailing Address - Fax:904-308-7514
Practice Address - Street 1:1 SHIRCLIFF WAY
Practice Address - Street 2:STE 1734
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32204
Practice Address - Country:US
Practice Address - Phone:904-308-7515
Practice Address - Fax:904-308-7514
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-03
Last Update Date:2024-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL022451100Medicaid
FL22451101Medicaid