Provider Demographics
NPI:1487613121
Name:DOCTORS MEMORIAL HOSPITAL INC
Entity type:Organization
Organization Name:DOCTORS MEMORIAL HOSPITAL INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CLINIC MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:KAREN
Authorized Official - Middle Name:
Authorized Official - Last Name:TIDWELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:850-223-5409
Mailing Address - Street 1:117 SW VIRGINIA CIR
Mailing Address - Street 2:
Mailing Address - City:MAYO
Mailing Address - State:FL
Mailing Address - Zip Code:32066-4065
Mailing Address - Country:US
Mailing Address - Phone:386-294-2475
Mailing Address - Fax:
Practice Address - Street 1:113 E MAIN ST
Practice Address - Street 2:
Practice Address - City:MAYO
Practice Address - State:FL
Practice Address - Zip Code:32066-4808
Practice Address - Country:US
Practice Address - Phone:386-294-2475
Practice Address - Fax:386-294-2478
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-21
Last Update Date:2012-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL660123500261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
24274COtherBCBS
FL660123500Medicaid
10D0961929OtherCLIA
FL660123500Medicaid