Basic Information
| Provider Information | |||||||||
| NPI: | 1356007439 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | FLORIDA HOSPITAL WATERMAN INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 770 W GRANADA BLVD STE 203 | ||||||||
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| City: | ORMOND BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 321745179 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3862314252 | ||||||||
| FaxNumber: | 3866762560 | ||||||||
| Practice Location | |||||||||
| Address1: | 1000 WATERMAN WAY | ||||||||
| Address2: | |||||||||
| City: | TAVARES | ||||||||
| State: | FL | ||||||||
| PostalCode: | 327785266 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3522533333 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/12/2021 | ||||||||
| LastUpdateDate: | 11/12/2021 | ||||||||
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| AuthorizedOfficialLastName: | WARREN | ||||||||
| AuthorizedOfficialFirstName: | TERRI | ||||||||
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| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 3522533300 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | FLORIDA HOSPITAL WATERMAN INC | ||||||||
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| NPICertificationDate: | 11/08/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR0404X | Y | Ambulatory Health Care Facilities | Clinic/Center | Rehabilitation, Cardiac Facilities |
ID Information
| ID | Type | State | Issuer | Description | 010109500 | 05 | FL | MEDICAID |