Basic Information
| Provider Information | |||||||||
| NPI: | 1013434067 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ADVENTIST HEALTH SYSTEM-SUNBELT INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | FROSTPROOF FAMILY HEALTH | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4101 SUN N LAKE BLVD | ||||||||
| Address2: | |||||||||
| City: | SEBRING | ||||||||
| State: | FL | ||||||||
| PostalCode: | 338722131 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8633144466 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 200 S SCENIC HWY | ||||||||
| Address2: | |||||||||
| City: | FROSTPROOF | ||||||||
| State: | FL | ||||||||
| PostalCode: | 338432125 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8635466384 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/29/2017 | ||||||||
| LastUpdateDate: | 08/29/2017 | ||||||||
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| AuthorizedOfficialLastName: | OLIVER | ||||||||
| AuthorizedOfficialFirstName: | ROSALIE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 8634023366 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | ADVENTIST HEALTH SYSTEM-SUNBELT INC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 363AM0700X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | 261QR1300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
ID Information
| ID | Type | State | Issuer | Description | 010260100 | 05 | FL | MEDICAID |