1063426823 NPI number — MEMORIAL HEALTH SYSTEMS INC

Table of content: (NPI 1063426823)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063426823 NPI number — MEMORIAL HEALTH SYSTEMS INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MEMORIAL HEALTH SYSTEMS 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:
FLORIDA HOSPITAL MEMORIAL MEDICAL CENTER
Provider Other Organization Name Type Code:
3
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:
1063426823
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/13/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
770 W GRANADA BLVD STE 203
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ORMOND BEACH
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32174-5179
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
386-231-4610
Provider Business Mailing Address Fax Number:
386-231-3342

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
301 MEMORIAL MEDICAL PKWY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DAYTONA BEACH
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32117-5167
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
386-231-6000
Provider Business Practice Location Address Fax Number:
386-231-3342
Provider Enumeration Date:
07/28/2006

Additional Information

Authorized Official

Authorized Official Last Name:
DOMAYER
Authorized Official First Name:
CORY
Authorized Official Middle Name:
Authorized Official Title or Position:
CFO
Authorized Official Telephone Number:
386-231-3906

Provider Taxonomy Codes

  • Taxonomy code: 261QR0404X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 282N00000X , with the licence number: 4201 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 010186900 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1063426823 . This is a "AETNA HMO" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 1063426823 . This is a "AETNA PPO" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 1063426823 . This is a "UHC" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 334 . This is a "BLUE CROSS" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 010186900 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2024 www.npivalidator.com