Basic Information
| Provider Information | |||||||||
| NPI: | 1013984863 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | FLORIDA DEPARTMENT OF HEALTH | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | MARTIN COUNTY HEALTH DEPARTMENT | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 3441 SE WILLOUGHBY BLVD | ||||||||
| Address2: | |||||||||
| City: | STUART | ||||||||
| State: | FL | ||||||||
| PostalCode: | 349945060 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7722214000 | ||||||||
| FaxNumber: | 7722214989 | ||||||||
| Practice Location | |||||||||
| Address1: | 3441 SE WILLOUGHBY BLVD | ||||||||
| Address2: | |||||||||
| City: | STUART | ||||||||
| State: | FL | ||||||||
| PostalCode: | 349945060 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7722214000 | ||||||||
| FaxNumber: | 7722214989 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/01/2006 | ||||||||
| LastUpdateDate: | 08/09/2012 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | PECK | ||||||||
| AuthorizedOfficialFirstName: | KARLETTE | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 7722214000 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251K00000X | Y | Agencies | Public Health or Welfare |
ID Information
| ID | Type | State | Issuer | Description | 027953600 | 05 | FL | MEDICAID |