Provider Demographics
NPI:1083941678
Name:ASCENSION SACRED HEART GULF
Entity Type:Organization
Organization Name:ASCENSION SACRED HEART GULF
Other - Org Name:ASCENSION SACRED HEART GULF
Other - Org Type:Doing Business As
Authorized Official - Title/Position:COO
Authorized Official - Prefix:
Authorized Official - First Name:COBA
Authorized Official - Middle Name:SUSAN
Authorized Official - Last Name:CORNEJO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:850-416-6206
Mailing Address - Street 1:7928 SOLUTION CTR
Mailing Address - Street 2:LOCKBOX 777928
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60677-7009
Mailing Address - Country:US
Mailing Address - Phone:850-416-7190
Mailing Address - Fax:850-416-7453
Practice Address - Street 1:3801 E HIGHWAY 98
Practice Address - Street 2:
Practice Address - City:PORT ST JOE
Practice Address - State:FL
Practice Address - Zip Code:32456-5318
Practice Address - Country:US
Practice Address - Phone:850-229-5600
Practice Address - Fax:850-416-7453
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-11-03
Last Update Date:2021-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL275N00000X, 282NR1301X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282NR1301XHospitalsGeneral Acute Care HospitalRural
No275N00000XHospital UnitsMedicare Defined Swing Bed Unit
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL159OtherBLUE CROSS OF FL
FL002012700Medicaid
FL100313Medicare Oscar/Certification
FL159OtherBLUE CROSS OF FL