Basic Information
Provider Information | |||||||||
NPI: | 1174523815 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | VICTORIA HEALTHCARE INC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | SELECT SPECIALTY HOSPITAL - MIAMI | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 4714 GETTYSBURG RD | ||||||||
Address2: | LEGAL DEPT. | ||||||||
City: | MECHANICSBURG | ||||||||
State: | PA | ||||||||
PostalCode: | 170554325 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7179721100 | ||||||||
FaxNumber: | 7179759981 | ||||||||
Practice Location | |||||||||
Address1: | 955 NW 3RD ST | ||||||||
Address2: |   | ||||||||
City: | MIAMI | ||||||||
State: | FL | ||||||||
PostalCode: | 331281274 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3054165737 | ||||||||
FaxNumber: | 3055458556 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/22/2005 | ||||||||
LastUpdateDate: | 09/02/2010 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | TARVIN | ||||||||
AuthorizedOfficialFirstName: | MICHAEL | ||||||||
AuthorizedOfficialMiddleName: | E. | ||||||||
AuthorizedOfficialTitleorPosition: | VICE PRESIDENT | ||||||||
AuthorizedOfficialTelephone: | 7179721100 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282E00000X | 4469 | FL | Y |   | Hospitals | Long Term Care Hospital |   |
ID Information
ID | Type | State | Issuer | Description | 595 | 01 | FL | BLUE CROSS FL | OTHER | SG071214 | 01 | FL | VISTA | OTHER | 010337300 | 05 | FL |   | MEDICAID | 271538 | 01 | FL | AMERIGROUP | OTHER |