Basic Information
| Provider Information | |||||||||
| NPI: | 1952351306 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | FLORIDA COMMUNITY HEALTH CENTERS INC | ||||||||
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| OtherOrganizationName: | LAKESHORE MEDICAL - ADULTS | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5827 CORPORATE WAY | ||||||||
| Address2: | |||||||||
| City: | WEST PALM BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 334072000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5618449443 | ||||||||
| FaxNumber: | 5618441013 | ||||||||
| Practice Location | |||||||||
| Address1: | 1100 N PARROTT AVE | ||||||||
| Address2: | |||||||||
| City: | OKEECHOBEE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 349722129 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8637637481 | ||||||||
| FaxNumber: | 8637635920 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/10/2006 | ||||||||
| LastUpdateDate: | 06/17/2016 | ||||||||
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| AuthorizedOfficialLastName: | GERVASI | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
| AuthorizedOfficialMiddleName: | F | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT & CEO | ||||||||
| AuthorizedOfficialTelephone: | 5618449443 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | 261QF0400X | N | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) | 207Q00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 029574407 | 05 | FL | MEDICAID | 029574406 | 05 | FL | MEDICAID |