Basic Information
| Provider Information | |||||||||
| NPI: | 1487932422 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | TALLAHASSEE MEMORIAL HEALTHCARE INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1607 SAINT JAMES CT STE 1 | ||||||||
| Address2: | |||||||||
| City: | TALLAHASSEE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 323085352 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8504317021 | ||||||||
| FaxNumber: | 8504316975 | ||||||||
| Practice Location | |||||||||
| Address1: | 1300 MEDICAL DR | ||||||||
| Address2: | |||||||||
| City: | TALLAHASSEE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 323084646 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8502160190 | ||||||||
| FaxNumber: | 8502160112 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/25/2011 | ||||||||
| LastUpdateDate: | 01/19/2022 | ||||||||
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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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| NPICertificationDate: | 01/19/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X | FL | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease | 207RC0001X | FL | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Clinical Cardiac Electrophysiology | 207RI0011X | FL | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Interventional Cardiology | 363A00000X | FL | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363L00000X | FL | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 207R00000X | FL | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 24766T | 01 | FL | BLUE CROSS BLUE SHIELD | OTHER | 375270421 | 05 | FL | MEDICAID |