Provider Demographics
NPI:1225097967
Name:DOCTORS MEMORIAL HOSPITAL
Entity Type:Organization
Organization Name:DOCTORS MEMORIAL HOSPITAL
Other - Org Name:DMH PEDIATRIC AND FAMILY MEDICINE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:
Authorized Official - Last Name:BROWN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:850-584-0885
Mailing Address - Street 1:333 N BYRON BUTLER PKWY
Mailing Address - Street 2:
Mailing Address - City:PERRY
Mailing Address - State:FL
Mailing Address - Zip Code:32347-2300
Mailing Address - Country:US
Mailing Address - Phone:850-584-0800
Mailing Address - Fax:850-584-0689
Practice Address - Street 1:1706 S JEFFERSON ST
Practice Address - Street 2:
Practice Address - City:PERRY
Practice Address - State:FL
Practice Address - Zip Code:32348-5611
Practice Address - Country:US
Practice Address - Phone:850-838-2121
Practice Address - Fax:850-838-1842
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-21
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
24274OtherBCBS
103978Medicare ID - Type Unspecified