Provider Demographics
NPI:1417901406
Name:FAWCETT MEMORIAL HOSPITAL, INC.
Entity Type:Organization
Organization Name:FAWCETT MEMORIAL HOSPITAL, INC.
Other - Org Name:HCA FLORIDA FAWCETT HOSPITAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:VICKIE
Authorized Official - Middle Name:
Authorized Official - Last Name:MAGUREAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:941-624-8122
Mailing Address - Street 1:21298 OLEAN BLVD
Mailing Address - Street 2:
Mailing Address - City:PORT CHARLOTTE
Mailing Address - State:FL
Mailing Address - Zip Code:33952-6705
Mailing Address - Country:US
Mailing Address - Phone:941-629-1181
Mailing Address - Fax:941-627-6142
Practice Address - Street 1:21298 OLEAN BLVD
Practice Address - Street 2:
Practice Address - City:PORT CHARLOTTE
Practice Address - State:FL
Practice Address - Zip Code:33952-6705
Practice Address - Country:US
Practice Address - Phone:941-629-1181
Practice Address - Fax:941-627-6142
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-22
Last Update Date:2022-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282N00000XHospitalsGeneral Acute Care Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
0007175OtherAETNA
FL011746300Medicaid
SC11643BMedicaid
NY01608460Medicaid
OH0968672Medicaid
GA20320OtherWELLCARE
FL571OtherBLUE CROSS
20320OtherWELLCARE/STAYWELL
FL000035953OtherHUMANA
MIHLFL0102Medicaid
032064700OtherBLACK LUNG
GA000616569XMedicaid
MI304862874Medicaid
NY01608460Medicaid