Basic Information
Provider Information | |||||||||
NPI: | 1295304343 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | ADVENTIST HEALTH SYSTEM SUNBELT, INC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | ADVENTHEALTH TOTAL HEALTH MANAGEMENT PRIMARY CARE PLUS CLERMONT | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2600 WESTHALL LN STE 300 | ||||||||
Address2: |   | ||||||||
City: | MAITLAND | ||||||||
State: | FL | ||||||||
PostalCode: | 327517107 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4072002300 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 1919 E HIGHWAY 50 STE 205 | ||||||||
Address2: |   | ||||||||
City: | CLERMONT | ||||||||
State: | FL | ||||||||
PostalCode: | 347111975 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4072002300 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/23/2021 | ||||||||
LastUpdateDate: | 11/09/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | BRADY | ||||||||
AuthorizedOfficialFirstName: | SCOTT | ||||||||
AuthorizedOfficialMiddleName: | C | ||||||||
AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
AuthorizedOfficialTelephone: | 4072002300 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | ADVENTIST HEALTH TOTAL HEALTH MANAGEMENT | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | MD | ||||||||
NPICertificationDate: | 11/09/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X |   |   | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |   |
ID Information
ID | Type | State | Issuer | Description | MEDICARE | 01 | FL | DL090B | OTHER |