1972170785 NPI number — SANTA ROSA HMA PHYSICIAN MANAGEMENT LLC

Table of content: (NPI 1972170785)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1972170785 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:
1972170785
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:
615-628-6877

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4264 AVALON BLVD
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:
32583-2808
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
850-994-0431
Provider Business Practice Location Address Fax Number:
850-994-7883
Provider Enumeration Date:
06/09/2021

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: 363LF0000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 374819726 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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