Basic Information
| Provider Information | |||||||||
| NPI: | 1861589178 | ||||||||
| 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: | 4101 NW 89TH BLVD | ||||||||
| Address2: | |||||||||
| City: | GAINESVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 326063813 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3522655491 | ||||||||
| FaxNumber: | 3523387190 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/06/2006 | ||||||||
| 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 | 273Y00000X | 4286 | FL | Y | Hospital Units | Rehabilitation Unit |
ID Information
| ID | Type | State | Issuer | Description | 010003000 | 05 | FL | MEDICAID |