Basic Information
| Provider Information | |||||||||
| NPI: | 1578659306 | ||||||||
| 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: | 922 E CALL ST | ||||||||
| Address2: | |||||||||
| City: | STARKE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 320913616 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9043682300 | ||||||||
| FaxNumber: | 3523733006 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/05/2006 | ||||||||
| LastUpdateDate: | 10/13/2017 | ||||||||
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| AuthorizedOfficialLastName: | JIMENEZ | ||||||||
| AuthorizedOfficialFirstName: | EDWARD | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 3527331500 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | SHANDS TEACHING HOSPITAL AND CLINICS INC | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR0200X | 4267 | FL | N | Ambulatory Health Care Facilities | Clinic/Center | Radiology | 261Q00000X | 4267 | FL | Y | Ambulatory Health Care Facilities | Clinic/Center |
ID Information
| ID | Type | State | Issuer | Description | CD2952 | 01 | FL | MEDICARE RAIL ROAD | OTHER | 257857300 | 05 | FL | MEDICAID |