Basic Information
| Provider Information | |||||||||
| NPI: | 1699874248 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SHANDS TEACHING HOSPITAL AND CLINICS, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 100172 | ||||||||
| Address2: | |||||||||
| City: | GAINESVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 326100172 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3526279045 | ||||||||
| FaxNumber: | 3526279049 | ||||||||
| Practice Location | |||||||||
| Address1: | 1600 SW ARCHER RD | ||||||||
| Address2: | |||||||||
| City: | GAINESVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 326103003 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3522650111 | ||||||||
| FaxNumber: | 3526279049 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/21/2006 | ||||||||
| LastUpdateDate: | 08/18/2021 | ||||||||
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| AuthorizedOfficialLastName: | JIMENEZ | ||||||||
| AuthorizedOfficialFirstName: | ED | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 3527331500 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| NPICertificationDate: | 08/18/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QE0700X | 4286 | FL | N | Ambulatory Health Care Facilities | Clinic/Center | End-Stage Renal Disease (ESRD) Treatment | 333600000X | 4286 | FL | N | Suppliers | Pharmacy | 335U00000X | 4 | FL | N | Suppliers | Organ Procurement Organization | 3416A0800X | N | Transportation Services | Ambulance | Air Transport | 3416L0300X | N | Transportation Services | Ambulance | Land Transport | 282N00000X | 4286 | FL | Y | Hospitals | General Acute Care Hospital |
ID Information
| ID | Type | State | Issuer | Description | 083921300 | 05 | FL | MEDICAID | CF9177 | 01 | FL | MEDICARE RAIL ROAD | OTHER |