Provider Demographics
NPI:1881708733
Name:JACKSONVILLE HEALTH CLINIC PA
Entity type:Organization
Organization Name:JACKSONVILLE HEALTH CLINIC PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SOUJANYA
Authorized Official - Middle Name:
Authorized Official - Last Name:SANGAM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:904-726-1797
Mailing Address - Street 1:P O BOX 16486
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32246-6486
Mailing Address - Country:US
Mailing Address - Phone:904-726-1797
Mailing Address - Fax:904-726-1798
Practice Address - Street 1:2030 SOUTHSIDE BOULEVARD
Practice Address - Street 2:SUITE C
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32216
Practice Address - Country:US
Practice Address - Phone:904-726-1797
Practice Address - Fax:904-726-1798
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-18
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLK7354Medicare ID - Type UnspecifiedGROUP PROVIDER NUMBER