Basic Information
| Provider Information | |||||||||
| NPI: | 1316096266 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | WINTER HAVEN HOSPITAL INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | MID FLORIDA MEDICAL SERVIES | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 200 AVENUE F NE | ||||||||
| Address2: | |||||||||
| City: | WINTER HAVEN | ||||||||
| State: | FL | ||||||||
| PostalCode: | 338814131 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8632931121 | ||||||||
| FaxNumber: | 8632916719 | ||||||||
| Practice Location | |||||||||
| Address1: | 200 AVENUE F NE | ||||||||
| Address2: | |||||||||
| City: | WINTER HAVEN | ||||||||
| State: | FL | ||||||||
| PostalCode: | 338814131 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8632931121 | ||||||||
| FaxNumber: | 8632916719 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/09/2007 | ||||||||
| LastUpdateDate: | 07/12/2011 | ||||||||
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| AuthorizedOfficialLastName: | MACDOUGALL | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF FINANCIAL OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 8632931121 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 273Y00000X | 3974 | FL | Y | Hospital Units | Rehabilitation Unit |
ID Information
| ID | Type | State | Issuer | Description | 98943 | 01 | FL | BC 1500 | OTHER | 010169903 | 05 | FL | MEDICAID | Z23 | 01 | FL | BC REH | OTHER | 507 | 01 | FL | BC UB | OTHER | 010169900 | 05 | FL | MEDICAID |