Provider Demographics
NPI:1366539090
Name:PERRY GENERAL & INTERNAL MEDICINE OF NORTHEAST FLORIDA INC
Entity type:Organization
Organization Name:PERRY GENERAL & INTERNAL MEDICINE OF NORTHEAST FLORIDA INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:TARSHA
Authorized Official - Middle Name:L
Authorized Official - Last Name:PERRY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:904-260-9502
Mailing Address - Street 1:1301 MONUMENT ROAD
Mailing Address - Street 2:SUITE 21
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32225
Mailing Address - Country:US
Mailing Address - Phone:904-724-9334
Mailing Address - Fax:904-725-3120
Practice Address - Street 1:1301 MONUMENT ROAD
Practice Address - Street 2:SUITE 21
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32225
Practice Address - Country:US
Practice Address - Phone:904-724-9334
Practice Address - Fax:904-725-3120
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-06
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME61123207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
F19958Medicare UPIN
FLK4618Medicare ID - Type Unspecified