1285302224 NPI number — SANTA ROSA HMA PHYSICIAN MANAGEMENT LLC

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 1285302224 NPI number — SANTA ROSA HMA PHYSICIAN MANAGEMENT LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SANTA ROSA HMA PHYSICIAN MANAGEMENT LLC
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:
Provider Other Organization Name Type Code:
6
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:
1285302224
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/16/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 689022
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FRANKLIN
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37068-9022
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
615-465-7211
Provider Business Mailing Address Fax Number:
615-469-6677

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5992 BERRYHILL RD STE 102
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MILTON
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32570-1018
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
850-981-3302
Provider Business Practice Location Address Fax Number:
850-626-5474
Provider Enumeration Date:
09/03/2021

Additional Information

Authorized Official

Authorized Official Last Name:
JACKSON
Authorized Official First Name:
JENNIFER
Authorized Official Middle Name:
L
Authorized Official Title or Position:
SR DIR PROV ENROLLMENT & ONBOARDING
Authorized Official Telephone Number:
615-465-3334

Provider Taxonomy Codes

  • Taxonomy code: 208800000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: PENDING , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 374819741 . 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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