Basic Information
| Provider Information | |||||||||
| NPI: | 1194910414 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ADVENTIST HEALTH SYSTEMS SUNBELT | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | FLORIDA HOSPITAL CENTRA CARE - FORMOSA | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 901 N LAKE DESTINY RD | ||||||||
| Address2: | SUITE 400 | ||||||||
| City: | MAITLAND | ||||||||
| State: | FL | ||||||||
| PostalCode: | 327514844 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4072002860 | ||||||||
| FaxNumber: | 4072001365 | ||||||||
| Practice Location | |||||||||
| Address1: | 7848 W IRLO BRONSON HWY | ||||||||
| Address2: | |||||||||
| City: | KISSIMMEE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 347471729 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4073977032 | ||||||||
| FaxNumber: | 4073977041 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/10/2007 | ||||||||
| LastUpdateDate: | 02/05/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BRADY | ||||||||
| AuthorizedOfficialFirstName: | SCOTT | ||||||||
| AuthorizedOfficialMiddleName: | C. | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 4072002860 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | ADVENTIST HEALTH SYSTEMS SUNBELT | ||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | M.D. | ||||||||
| NPICertificationDate: | 02/05/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332900000X | ME 38110 | FL | Y | Suppliers | Non-Pharmacy Dispensing Site |
No ID Information.