Basic Information
| Provider Information | |||||||||
| NPI: | 1346519816 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ST. JOSEPH'S HOSPITAL, INC. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | ST. JOSEPH'S WOMEN'S HOSPITAL | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3001 W DR MLK JR. BLVD | ||||||||
| Address2: | |||||||||
| City: | TAMPA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 336076307 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8138704000 | ||||||||
| FaxNumber: | 8138704639 | ||||||||
| Practice Location | |||||||||
| Address1: | 3030 W. DR. MLK JR BLVD | ||||||||
| Address2: | |||||||||
| City: | TAMPA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 336076307 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8138704000 | ||||||||
| FaxNumber: | 8138704639 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/29/2011 | ||||||||
| LastUpdateDate: | 11/23/2019 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | GORKEN | ||||||||
| AuthorizedOfficialFirstName: | LYNDA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | VP, PATIENT FINANCIAL SERVICES | ||||||||
| AuthorizedOfficialTelephone: | 7272819479 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | ST. JOSEPH'S HOSPITAL, INC. | ||||||||
| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282N00000X | 4292 | FL | Y | Hospitals | General Acute Care Hospital |
ID Information
| ID | Type | State | Issuer | Description | FL0100978-02 | 05 | FL | MEDICAID |