Basic Information
| Provider Information | |||||||||
| NPI: | 1225034234 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | FLORIDA HOSPITAL MEDICAL GROUP INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | ADVENTHEALTH MEDICAL GROUP | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2600 WESTHALL LN FL 4 | ||||||||
| Address2: | |||||||||
| City: | MAITLAND | ||||||||
| State: | FL | ||||||||
| PostalCode: | 327517102 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4072002700 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2600 WESTHALL LN FL 4 | ||||||||
| Address2: | |||||||||
| City: | MAITLAND | ||||||||
| State: | FL | ||||||||
| PostalCode: | 327517102 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4072002700 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/23/2005 | ||||||||
| LastUpdateDate: | 06/15/2021 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | WYLIE | ||||||||
| AuthorizedOfficialFirstName: | WARREN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 4072002700 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | II | ||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 06/15/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103G00000X | NA | FL | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Clinical Neuropsychologist | 204F00000X | NA | FL | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Transplant Surgery | 207R00000X | NA | FL | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | 207RH0003X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology & Oncology | 207V00000X | NA | FL | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | 207X00000X | NA | FL | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | 208000000X | NA | FL | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | 2084P0800X | NA | FL | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry | 208600000X | NA | FL | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery | 208C00000X | NA | FL | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Colon & Rectal Surgery | 208D00000X | NA | FL | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | General Practice | 208M00000X | NA | FL | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Hospitalist | 363A00000X | NA | FL | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363L00000X | NA | FL | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 207Q00000X | NA | FL | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 252226804 | 05 | FL | MEDICAID | 252226810 | 05 | FL | MEDICAID | 252226814 | 05 | FL | MEDICAID | 24567 | 01 | FL | BCBS FL | OTHER | 252226800 | 05 | FL | MEDICAID | 252226802 | 05 | FL | MEDICAID | 252226809 | 05 | FL | MEDICAID | 252226811 | 05 | FL | MEDICAID | 252226807 | 05 | FL | MEDICAID | 252226812 | 05 | FL | MEDICAID | 252226813 | 05 | FL | MEDICAID | 252226818 | 05 | FL | MEDICAID | 252226801 | 05 | FL | MEDICAID | 252226806 | 05 | FL | MEDICAID | 252226805 | 05 | FL | MEDICAID | 252226808 | 05 | FL | MEDICAID |