1801320528 NPI number — DEDICATED SENIOR MEDICAL CENTER ST. PETERSBURG, 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 1801320528 NPI number — DEDICATED SENIOR MEDICAL CENTER ST. PETERSBURG, LLC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DEDICATED SENIOR MEDICAL CENTER ST. PETERSBURG, 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:
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:
1801320528
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/19/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1395 NW 167TH STREET
Provider Second Line Business Mailing Address:
CHEN MEDICAL CORPORATE OFFICE
Provider Business Mailing Address City Name:
MIAMI GARDENS
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33169
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
305-831-4761
Provider Business Mailing Address Fax Number:
305-831-4761

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
901 22ND AVENUE SOUTH
Provider Second Line Business Practice Location Address:
DEDICATED SENIOR MEDICAL CENTER ST. PETERSBURG, LLC.
Provider Business Practice Location Address City Name:
ST. PETERSBURG
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33705
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
305-831-4761
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/19/2017

Additional Information

Authorized Official

Authorized Official Last Name:
FERNANDEZ-CORTES
Authorized Official First Name:
GLADYS
Authorized Official Middle Name:
Authorized Official Title or Position:
MANAGING DIRECTOR
Authorized Official Telephone Number:
305-498-4034

Provider Taxonomy Codes

  • Taxonomy code: 174400000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 332900000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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





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