Provider Demographics
NPI:1033542485
Name:EMORY MEDICAL CORPORATION
Entity Type:Organization
Organization Name:EMORY MEDICAL CORPORATION
Other - Org Name:WOMEN'S CENTER OF FLORIDA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:AMANDA
Authorized Official - Middle Name:
Authorized Official - Last Name:BOLT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:386-466-1106
Mailing Address - Street 1:PO BOX 1646
Mailing Address - Street 2:
Mailing Address - City:LAKE CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32056-1646
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1546 S WATER ST
Practice Address - Street 2:STE. A
Practice Address - City:STARKE
Practice Address - State:FL
Practice Address - Zip Code:32091-4511
Practice Address - Country:US
Practice Address - Phone:904-964-4777
Practice Address - Fax:904-964-4780
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:EMORY MEDICAL CORPORATION
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-08-20
Last Update Date:2013-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL2093174400000X
261QP2300X, 261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
No261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural HealthGroup - Single Specialty