Basic Information
| Provider Information | |||||||||
| NPI: | 1114330800 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ADVENTIST HEALTH SYSTEM/SUNBELT, INC. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | ADVENTHEALTH CENTRA CARE -SOUTH TAMPA | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 2600 WESTHALL LANE BOX 300 | ||||||||
| Address2: | |||||||||
| City: | MAITLAND | ||||||||
| State: | FL | ||||||||
| PostalCode: | 32751 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4072002300 | ||||||||
| FaxNumber: | 4072001353 | ||||||||
| Practice Location | |||||||||
| Address1: | 301 N DALE MABRY HWY | ||||||||
| Address2: | |||||||||
| City: | TAMPA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 33609 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8132840985 | ||||||||
| FaxNumber: | 8132840986 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/10/2014 | ||||||||
| LastUpdateDate: | 02/05/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BRADY | ||||||||
| AuthorizedOfficialFirstName: | SCOTT | ||||||||
| AuthorizedOfficialMiddleName: | C | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT/CEO | ||||||||
| AuthorizedOfficialTelephone: | 4072002300 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | ADVENTIST HEALTH SYSTEM SUNBELT HC CO | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 02/05/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QU0200X | 261QU0200X | N | Ambulatory Health Care Facilities | Clinic/Center | Urgent Care | 261QU0200X | FL | Y | Ambulatory Health Care Facilities | Clinic/Center | Urgent Care |
ID Information
| ID | Type | State | Issuer | Description | 013961700 | 05 | FL | MEDICAID |