Basic Information
| Provider Information | |||||||||
| NPI: | 1104250786 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | FLORIDA COMMUNITY HEALTH CENTERS, INC. | ||||||||
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| OtherOrganizationName: | GRACE WOMEN'S HEALTH CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5827 CORPORATE WAY | ||||||||
| Address2: | |||||||||
| City: | WEST PALM BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 334072000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5618449443 | ||||||||
| FaxNumber: | 5618441013 | ||||||||
| Practice Location | |||||||||
| Address1: | 2402 FRIST BLVD | ||||||||
| Address2: | SUITE 202 | ||||||||
| City: | FORT PIERCE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 349504838 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7724293400 | ||||||||
| FaxNumber: | 7724293410 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/30/2013 | ||||||||
| LastUpdateDate: | 06/17/2016 | ||||||||
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| AuthorizedOfficialLastName: | GERVASI | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
| AuthorizedOfficialMiddleName: | F | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT AND CEO | ||||||||
| AuthorizedOfficialTelephone: | 5618449443 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | D.O. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | 363LX0001X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Obstetrics & Gynecology | 367A00000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Advanced Practice Midwife | 261QF0400X | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
No ID Information.