Basic Information
| Provider Information | |||||||||
| NPI: | 1396804373 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SHANDS TEACHING HOSPITAL AND CLINICS, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 100345 | ||||||||
| Address2: | |||||||||
| City: | GAINESVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 326100345 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3526279045 | ||||||||
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| Practice Location | |||||||||
| Address1: | 4197 NW 86TH TERRACE | ||||||||
| Address2: | SUITE 1131 | ||||||||
| City: | GAINESVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 326066271 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3527330090 | ||||||||
| FaxNumber: | 3527330098 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/06/2006 | ||||||||
| LastUpdateDate: | 08/03/2018 | ||||||||
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| AuthorizedOfficialLastName: | JIMENEZ | ||||||||
| AuthorizedOfficialFirstName: | EDWARD | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 3527331500 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 3336C0003X | PH13786 | FL | N | Suppliers | Pharmacy | Community/Retail Pharmacy | 333600000X | PH13786 | FL | Y | Suppliers | Pharmacy |
ID Information
| ID | Type | State | Issuer | Description | P3733 | 01 | FL | BCBS PROVIDER NUMBER | OTHER | DSH100113C | 01 | FL | 340B NUMBER | OTHER | 1040308 | 01 | FL | NCPDP NUMBER | OTHER | 106077500 | 05 | FL | MEDICAID | 1396804373 | 01 | FL | NPI NUMBER | OTHER | BS4749581 | 01 | FL | PHARMACY DEA NUMBER | OTHER |