Provider Demographics
NPI:1285683045
Name:TALLAHASSEE MEMORIAL HEALTHCARE INC
Entity Type:Organization
Organization Name:TALLAHASSEE MEMORIAL HEALTHCARE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBIN
Authorized Official - Middle Name:L
Authorized Official - Last Name:MOSS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:850-431-6256
Mailing Address - Street 1:1607 SAINT JAMES CT STE 1
Mailing Address - Street 2:
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32308-5352
Mailing Address - Country:US
Mailing Address - Phone:850-431-7021
Mailing Address - Fax:850-431-6975
Practice Address - Street 1:15 COUNCIL MOORE RD
Practice Address - Street 2:
Practice Address - City:CRAWFORDVILLE
Practice Address - State:FL
Practice Address - Zip Code:32327-3117
Practice Address - Country:US
Practice Address - Phone:850-926-7105
Practice Address - Fax:850-926-2034
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-09
Last Update Date:2019-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207Q00000X
FL261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL24766HOtherBCBS GROUP #
FL375270406Medicaid
FL660037903Medicaid
FL660037903Medicaid
FL375270406Medicaid