Basic Information
| Provider Information | |||||||||
| NPI: | 1851825343 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ADVENTIST HEALTH SYSTEM/SUNBELT, INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | ADVENTHEALTH TOTAL HEALTH MANAGEMENT PRIMARY CARE PLUS - ST. CLOUD | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2600 WESTHALL LANE BOX 300 | ||||||||
| Address2: | |||||||||
| City: | MAITLAND | ||||||||
| State: | FL | ||||||||
| PostalCode: | 32751 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4072002300 | ||||||||
| FaxNumber: | 4072001353 | ||||||||
| Practice Location | |||||||||
| Address1: | 4660 13TH ST | ||||||||
| Address2: | |||||||||
| City: | SAINT CLOUD | ||||||||
| State: | FL | ||||||||
| PostalCode: | 347696765 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4072002300 | ||||||||
| FaxNumber: | 4072001353 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/12/2017 | ||||||||
| LastUpdateDate: | 11/04/2021 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BRADY | ||||||||
| AuthorizedOfficialFirstName: | SCOTT | ||||||||
| AuthorizedOfficialMiddleName: | C | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT / CEO | ||||||||
| AuthorizedOfficialTelephone: | 4072002300 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | ADVENTIST HEALTH SYSTEM/SUNBELT, INC. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 11/04/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.