Basic Information
| Provider Information | |||||||||
| NPI: | 1306369657 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | TALLAHASSEE MEMORIAL HEALTHCARE INC | ||||||||
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| OtherOrganizationName: | MADISON COUNTY MEMORIAL HOSPITAL | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1300 MEDICAL DRIVE | ||||||||
| Address2: | BILLING DEPARTMENT | ||||||||
| City: | TALLAHASSEE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 323084622 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8502160100 | ||||||||
| FaxNumber: | 8502160180 | ||||||||
| Practice Location | |||||||||
| Address1: | 224 NW CRANE AVE | ||||||||
| Address2: | |||||||||
| City: | MADISON | ||||||||
| State: | FL | ||||||||
| PostalCode: | 323401400 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8509732271 | ||||||||
| FaxNumber: | 8509732818 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/19/2017 | ||||||||
| LastUpdateDate: | 06/16/2018 | ||||||||
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| AuthorizedOfficialLastName: | MOSS | ||||||||
| AuthorizedOfficialFirstName: | ROBIN | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 8504316256 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
| ID | Type | State | Issuer | Description | 375270421 | 05 | FL | MEDICAID |