Provider Demographics
NPI:1508105610
Name:SACRED HEART ON THE GULF
Entity Type:Organization
Organization Name:SACRED HEART ON THE GULF
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:REHAB. MANAGER
Authorized Official - Prefix:MISS
Authorized Official - First Name:JOSE AURELIO
Authorized Official - Middle Name:
Authorized Official - Last Name:SANTIESTEBAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:850-229-5752
Mailing Address - Street 1:3801 E HIGHWAY 98
Mailing Address - Street 2:
Mailing Address - City:PORT ST JOE
Mailing Address - State:FL
Mailing Address - Zip Code:32456-5318
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3801 E HIGHWAY 98
Practice Address - Street 2:
Practice Address - City:PORT ST JOE
Practice Address - State:FL
Practice Address - Zip Code:32456-5318
Practice Address - Country:US
Practice Address - Phone:850-229-5752
Practice Address - Fax:850-227-7999
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SACRED HEART HEALTH SYSTEM
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-02-08
Last Update Date:2013-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT27432283X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes283X00000XHospitalsRehabilitation Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL002012700Medicaid
FL100313Medicare UPIN