Basic Information
| Provider Information | |||||||||
| NPI: | 1740443589 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | COMMUNITY HEALTH OF SOUTH FLORIDA, INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | MARATHON HEALTH CENTER | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10300 SW 216TH ST | ||||||||
| Address2: | |||||||||
| City: | MIAMI | ||||||||
| State: | FL | ||||||||
| PostalCode: | 331901003 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3052535100 | ||||||||
| FaxNumber: | 3052544987 | ||||||||
| Practice Location | |||||||||
| Address1: | 2805 OVERSEAS HWY | ||||||||
| Address2: | |||||||||
| City: | MARATHON | ||||||||
| State: | FL | ||||||||
| PostalCode: | 330502239 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3057434000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/02/2008 | ||||||||
| LastUpdateDate: | 08/29/2019 | ||||||||
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| AuthorizedOfficialLastName: | HARTLEY | ||||||||
| AuthorizedOfficialFirstName: | BRODES | ||||||||
| AuthorizedOfficialMiddleName: | H | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 3052535100 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNameSuffix: | JR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
| ID | Type | State | Issuer | Description | 029572825 | 05 | FL | MEDICAID | 029572824 | 05 | FL | MEDICAID |