Provider Demographics
NPI:1811927650
Name:MEMORIAL NEUROSURGERY GROUP LLC
Entity type:Organization
Organization Name:MEMORIAL NEUROSURGERY GROUP LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
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:850-523-2117
Mailing Address - Street 1:4063 SALISBURY RD
Mailing Address - Street 2:SUITE 210
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32216-8030
Mailing Address - Country:US
Mailing Address - Phone:904-296-2522
Mailing Address - Fax:904-296-8173
Practice Address - Street 1:4063 SALISBURY RD
Practice Address - Street 2:SUITE 210
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32216-8030
Practice Address - Country:US
Practice Address - Phone:904-296-2522
Practice Address - Fax:904-296-8173
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-04
Last Update Date:2007-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLAD379Medicare PIN