Basic Information
Provider Information | |||||||||
NPI: | 1588180475 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | SACRED HEART HEALTH SYSTEM, INC. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | SACRED HEART MEDICAL GROUP #03 | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 2699 | ||||||||
Address2: | ATTN: HPE | ||||||||
City: | PENSACOLA | ||||||||
State: | FL | ||||||||
PostalCode: | 325132699 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8504754620 | ||||||||
FaxNumber: | 8504754619 | ||||||||
Practice Location | |||||||||
Address1: | 4033 GULF BREEZE PKWY | ||||||||
Address2: | STE D | ||||||||
City: | GULF BREEZE | ||||||||
State: | FL | ||||||||
PostalCode: | 32563 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8504949000 | ||||||||
FaxNumber: | 8504161248 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/22/2017 | ||||||||
LastUpdateDate: | 09/25/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | FOLEY | ||||||||
AuthorizedOfficialFirstName: | JAN | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | ENROLLMENT COORDINATOR | ||||||||
AuthorizedOfficialTelephone: | 8504754620 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | SACRED HEART HEALTH SYSTEM, INC. | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
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.