Basic Information
| Provider Information | |||||||||
| NPI: | 1396727277 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CANTONMENT MEDICAL CENTER, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 748 N HIGHWAY 29 | ||||||||
| Address2: | |||||||||
| City: | CANTONMENT | ||||||||
| State: | FL | ||||||||
| PostalCode: | 325339513 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8509374004 | ||||||||
| FaxNumber: | 8509374006 | ||||||||
| Practice Location | |||||||||
| Address1: | 748 N HIGHWAY 29 | ||||||||
| Address2: | |||||||||
| City: | CANTONMENT | ||||||||
| State: | FL | ||||||||
| PostalCode: | 325339513 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8509374004 | ||||||||
| FaxNumber: | 8509374006 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/16/2005 | ||||||||
| LastUpdateDate: | 04/20/2008 | ||||||||
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| AuthorizedOfficialLastName: | SALIB | ||||||||
| AuthorizedOfficialFirstName: | FADEL | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 8509374004 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | ME87968 | FL | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 2084P0800X | ME70527 | FL | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | 44104 | 01 | FL | BCBS FL | OTHER |