Provider Demographics
NPI:1093748162
Name:OGLETHORPE OF PORT ST LUCIE LLC
Entity Type:Organization
Organization Name:OGLETHORPE OF PORT ST LUCIE LLC
Other - Org Name:PORT ST LUCIE HOSPITAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR/ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:EDMUND
Authorized Official - Last Name:O'SHEA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:813-978-1933
Mailing Address - Street 1:2550 SE WALTON RD
Mailing Address - Street 2:
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34952-7168
Mailing Address - Country:US
Mailing Address - Phone:772-335-0400
Mailing Address - Fax:772-337-3124
Practice Address - Street 1:18302 HIGHWOODS PRESERVE PKWY
Practice Address - Street 2:SUITE 114
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33647-1758
Practice Address - Country:US
Practice Address - Phone:813-978-1933
Practice Address - Fax:813-978-1951
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-09
Last Update Date:2009-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes283Q00000XHospitalsPsychiatric Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL104070Medicare ID - Type UnspecifiedMEDICARE NUMBER