Provider Demographics
NPI:1043260490
Name:FLORIDA COMMUNITY HEALTH CENTERS INC
Entity Type:Organization
Organization Name:FLORIDA COMMUNITY HEALTH CENTERS INC
Other - Org Name:LAKESHORE PEDIATRICS ANNEX
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT & CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:F
Authorized Official - Last Name:GERVASI
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:561-844-9443
Mailing Address - Street 1:4450 S TIFFANY DR
Mailing Address - Street 2:
Mailing Address - City:WEST PALM BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33407-3241
Mailing Address - Country:US
Mailing Address - Phone:561-844-9443
Mailing Address - Fax:561-844-1013
Practice Address - Street 1:4450 S TIFFANY DR
Practice Address - Street 2:
Practice Address - City:WEST PALM BEACH
Practice Address - State:FL
Practice Address - Zip Code:33407-3241
Practice Address - Country:US
Practice Address - Phone:561-844-9443
Practice Address - Fax:561-844-1013
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-10
Last Update Date:2011-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)Group - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL029574414Medicaid
FL029574415Medicaid
FL029574415Medicaid
FL101855Medicare Oscar/Certification