Provider Demographics
NPI:1174539522
Name:TALLAHASSEE MEMORIAL HEALTHCARE INC
Entity type:Organization
Organization Name:TALLAHASSEE MEMORIAL HEALTHCARE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:O'BRYANT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:850-431-5380
Mailing Address - Street 1:1300 MICCOSUKEE RD
Mailing Address - Street 2:
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32308-5054
Mailing Address - Country:US
Mailing Address - Phone:850-431-5380
Mailing Address - Fax:850-431-5883
Practice Address - Street 1:1619 PHYSICIANS DR
Practice Address - Street 2:
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32308-4620
Practice Address - Country:US
Practice Address - Phone:850-431-6800
Practice Address - Fax:850-431-6855
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-31
Last Update Date:2019-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL20480096251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL027086500Medicaid
FL027086500Medicaid