Provider Demographics
NPI:1386766616
Name:BETTY ANNE MINCEY MD PA
Entity type:Organization
Organization Name:BETTY ANNE MINCEY MD PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:SHARE HOLDER
Authorized Official - Prefix:DR
Authorized Official - First Name:BETTY
Authorized Official - Middle Name:ANNE
Authorized Official - Last Name:MINCEY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:904-241-8069
Mailing Address - Street 1:2370 3RD ST S
Mailing Address - Street 2:SUITE 1
Mailing Address - City:JACKSONVILLE BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32250-4023
Mailing Address - Country:US
Mailing Address - Phone:904-241-8069
Mailing Address - Fax:904-241-8071
Practice Address - Street 1:2370 3RD ST S
Practice Address - Street 2:SUITE 1
Practice Address - City:JACKSONVILLE BEACH
Practice Address - State:FL
Practice Address - Zip Code:32250-4023
Practice Address - Country:US
Practice Address - Phone:904-241-8069
Practice Address - Fax:904-241-8071
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-06
Last Update Date:2012-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0071603207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLD9421Medicare ID - Type Unspecified