Basic Information
| Provider Information | |||||||||
| NPI: | 1689050965 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | FLAGLER HOSPITAL, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 400 HEALTH PARK BLVD | ||||||||
| Address2: | |||||||||
| City: | SAINT AUGUSTINE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 320865784 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9048195155 | ||||||||
| FaxNumber: | 9048194906 | ||||||||
| Practice Location | |||||||||
| Address1: | 101 HEALTH PARK BLVD | ||||||||
| Address2: | |||||||||
| City: | SAINT AUGUSTINE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 320865777 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9048195155 | ||||||||
| FaxNumber: | 9048194906 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/10/2015 | ||||||||
| LastUpdateDate: | 08/10/2015 | ||||||||
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| AuthorizedOfficialLastName: | GORDY | ||||||||
| AuthorizedOfficialFirstName: | JOSEPH | ||||||||
| AuthorizedOfficialMiddleName: | S | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO/PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 9048194400 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR0200X | 3665 | FL | Y | Ambulatory Health Care Facilities | Clinic/Center | Radiology |
ID Information
| ID | Type | State | Issuer | Description | 010171100 | 05 | FL | MEDICAID |