Provider Demographics
NPI:1154074847
Name:FLORIDA DEPARTMENT OF HEALTH, CHILDREN'S MEDICAL SERVICES HEALTH PLAN
Entity Type:Organization
Organization Name:FLORIDA DEPARTMENT OF HEALTH, CHILDREN'S MEDICAL SERVICES HEALTH PLAN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:ANDREA
Authorized Official - Middle Name:
Authorized Official - Last Name:GARY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:850-245-4738
Mailing Address - Street 1:4052 BALD CYPRESS WAY BIN #A06
Mailing Address - Street 2:
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32399-1707
Mailing Address - Country:US
Mailing Address - Phone:850-245-4200
Mailing Address - Fax:850-617-6466
Practice Address - Street 1:2585 MERCHANTS ROW BLVD
Practice Address - Street 2:
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32399-6607
Practice Address - Country:US
Practice Address - Phone:850-245-4200
Practice Address - Fax:850-617-6466
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-02-02
Last Update Date:2022-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251K00000XAgenciesPublic Health or Welfare
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL100992708Medicaid