NPIMap

Organization Active NPI

Southeastern Neuroscience Institute PA

  • Specialist
  • Jacksonville, FL
National Provider Identifier
1700099017
Registry record updated May 20, 2008
On this page

Key facts

NPPES NPI Registry
Primary specialty
SpecialistTaxonomy code 174400000X
License
ME0013636 Issued in FL
Legal business name
SOUTHEASTERN NEUROSCIENCE INSTITUTE PA
Practice address
3728 Phillips Hwy
Suite 31
Jacksonville, FL 32207-9300
Phone
(904) 346-0707
Fax
(904) 396-4300
NPI assigned
May 7, 2007
Last updated
May 20, 2008By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on May 20, 2008

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Dr. Jacob Green, MD, PH.D
Title
Ceo, Neurologist
Phone
(904) 346-0707

Specialties & licenses 3

Specialty (taxonomy)CodeLicenseStatePrimary
SpecialistGroup: 193200000X MULTI-SPECIALTY GROUP 174400000X ME0013636 FL Primary
SpecialistGroup: 193200000X MULTI-SPECIALTY GROUP 174400000X ME 59265 FL
SpecialistGroup: 193200000X MULTI-SPECIALTY GROUP 174400000X ME45606 FL

Addresses

Primary practice location

3728 Phillips Hwy
Suite 31
Jacksonville, FL 32207-9300

Mailing address

3728 Phillips Hwy
Suite 32
Jacksonville, FL 32207-9300
Phone (904) 346-0707

Other identifiers 3

IdentifierTypeStateIssuer
059852600MedicaidFL
380447000MedicaidFL
266403800MedicaidFL

National Provider Directory

National Provider Directory

Locations

3728 Philips Hwy
Ste 32
Jacksonville, FL 32207
Phone (904) 346-0707

3728 Philips Hwy
Ste 31
Jacksonville, FL 32207
Phone (904) 346-0707

65 Lewis Blvd
Ste 100
Saint Augustine, FL 32084

Practitioners & affiliated clinicians

Practitioners 3

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1178496000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1211241600000",
    "number": "1700099017",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "3728 PHILLIPS HWY",
            "address_2": "SUITE 32",
            "city": "JACKSONVILLE",
            "state": "FL",
            "postal_code": "322079300",
            "telephone_number": "904-346-0707",
            "fax_number": "904-396-4300"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "3728 PHILLIPS HWY",
            "address_2": "SUITE 31",
            "city": "JACKSONVILLE",
            "state": "FL",
            "postal_code": "322079300",
            "telephone_number": "904-346-0707",
            "fax_number": "904-396-4300"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "SOUTHEASTERN NEUROSCIENCE INSTITUTE PA",
        "organizational_subpart": "NO",
        "enumeration_date": "2007-05-07",
        "last_updated": "2008-05-20",
        "status": "A",
        "authorized_official_last_name": "GREEN",
        "authorized_official_first_name": "JACOB",
        "authorized_official_title_or_position": "CEO, NEUROLOGIST",
        "authorized_official_telephone_number": "904-346-0707",
        "authorized_official_name_prefix": "Dr.",
        "authorized_official_credential": "MD, PH.D"
    },
    "taxonomies": [
        {
            "code": "174400000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Specialist",
            "state": "FL",
            "license": "ME0013636",
            "primary": true
        },
        {
            "code": "174400000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Specialist",
            "state": "FL",
            "license": "ME 59265",
            "primary": false
        },
        {
            "code": "174400000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Specialist",
            "state": "FL",
            "license": "ME45606",
            "primary": false
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "059852600",
            "state": "FL"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "380447000",
            "state": "FL"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "266403800",
            "state": "FL"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Jacksonville, FL

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on May 20, 2008; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.