1558344978 NPI number — ST VINCENTS AMBULATORY CARE INC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1558344978 NPI number — ST VINCENTS AMBULATORY CARE INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ST VINCENTS AMBULATORY CARE INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
HILLIARD MEDICAL CENTER, INC.
Provider Other Organization Name Type Code:
4
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1558344978
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/26/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
551616 US HIGHWAY 1
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HILLIARD
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32046-8281
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
904-845-3574
Provider Business Mailing Address Fax Number:
904-845-7418

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
551616 US HIGHWAY 1
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HILLIARD
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32046-8281
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
904-845-3574
Provider Business Practice Location Address Fax Number:
904-845-7418
Provider Enumeration Date:
11/21/2005

Additional Information

Authorized Official

Authorized Official Last Name:
GOODEN
Authorized Official First Name:
LINDA
Authorized Official Middle Name:
E
Authorized Official Title or Position:
AMG ADMINISTRATION
Authorized Official Telephone Number:
904-450-8288

Provider Taxonomy Codes

  • Taxonomy code: 261QR1300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 363LF0000X , with the licence number: ARNP1440112 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 024917965 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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