Provider Demographics
NPI:1184674384
Name:CHIEFLAND MEDICAL CENTER LLC
Entity Type:Organization
Organization Name:CHIEFLAND MEDICAL CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXEC DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:L
Authorized Official - Last Name:CONNOLE
Authorized Official - Suffix:II
Authorized Official - Credentials:
Authorized Official - Phone:352-493-9500
Mailing Address - Street 1:1113 NW 23RD AVE
Mailing Address - Street 2:
Mailing Address - City:CHIEFLAND
Mailing Address - State:FL
Mailing Address - Zip Code:32626-1911
Mailing Address - Country:US
Mailing Address - Phone:352-493-9500
Mailing Address - Fax:352-493-7070
Practice Address - Street 1:1113 NW 23RD AVE
Practice Address - Street 2:
Practice Address - City:CHIEFLAND
Practice Address - State:FL
Practice Address - Zip Code:32626-1911
Practice Address - Country:US
Practice Address - Phone:352-493-9500
Practice Address - Fax:352-493-7070
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-11
Last Update Date:2007-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLHCC4256207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL21419OtherBCBS
FL21419OtherBCBS
FLK7290Medicare PIN