Basic Information
| Provider Information | |||||||||
| NPI: | 1164685756 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | WUESTHOFF MEMORIAL HOSPITAL INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 110 LONGWOOD AVE | ||||||||
| Address2: | MAIL STOP #24 | ||||||||
| City: | ROCKLEDGE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 329552828 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3216362211 | ||||||||
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| Practice Location | |||||||||
| Address1: | 110 LONGWOOD AVE | ||||||||
| Address2: | MAIL STOP #24 | ||||||||
| City: | ROCKLEDGE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 329552828 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3216362211 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/03/2008 | ||||||||
| LastUpdateDate: | 07/03/2008 | ||||||||
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| AuthorizedOfficialLastName: | FAYER | ||||||||
| AuthorizedOfficialFirstName: | GEORGE | ||||||||
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| AuthorizedOfficialTitleorPosition: | SVP CFO | ||||||||
| AuthorizedOfficialTelephone: | 3216362211 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | WUESTHOFF MEMORIAL HOSPITAL INC | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208G00000X | 4132 | FL | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Thoracic Surgery (Cardiothoracic Vascular Surgery) |
ID Information
| ID | Type | State | Issuer | Description | 271959200 | 05 | FL | MEDICAID |