Basic Information
| Provider Information | |||||||||
| NPI: | 1306363007 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SACRED HEART HEALTH SYSTEM, INC. | ||||||||
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| OtherOrganizationName: | SACRED HEART MEDICAL GROUP #04 | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2699 | ||||||||
| Address2: | ATTN: HPE | ||||||||
| City: | PENSACOLA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 325132699 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8504754620 | ||||||||
| FaxNumber: | 8504754619 | ||||||||
| Practice Location | |||||||||
| Address1: | 4521 N DAVIS HWY | ||||||||
| Address2: | |||||||||
| City: | PENSACOLA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 325032770 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8504949002 | ||||||||
| FaxNumber: | 8504773912 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/24/2017 | ||||||||
| LastUpdateDate: | 05/12/2021 | ||||||||
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| AuthorizedOfficialLastName: | HEMM | ||||||||
| AuthorizedOfficialFirstName: | MIRANDA | ||||||||
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| AuthorizedOfficialTitleorPosition: | ENROLLMENT MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 9044506004 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | SACRED HEART HEALTH SYSTEM, INC. | ||||||||
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| NPICertificationDate: | 05/12/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | FL | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
No ID Information.