Provider Demographics
NPI:1558344978
Name:ST VINCENTS AMBULATORY CARE INC
Entity Type:Organization
Organization Name:ST VINCENTS AMBULATORY CARE INC
Other - Org Name:HILLIARD MEDICAL CENTER, INC.
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:AMG ADMINISTRATION
Authorized Official - Prefix:
Authorized Official - First Name:LINDA
Authorized Official - Middle Name:E
Authorized Official - Last Name:GOODEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:904-450-8288
Mailing Address - Street 1:551616 US HIGHWAY 1
Mailing Address - Street 2:
Mailing Address - City:HILLIARD
Mailing Address - State:FL
Mailing Address - Zip Code:32046-8281
Mailing Address - Country:US
Mailing Address - Phone:904-845-3574
Mailing Address - Fax:904-845-7418
Practice Address - Street 1:551616 US HIGHWAY 1
Practice Address - Street 2:
Practice Address - City:HILLIARD
Practice Address - State:FL
Practice Address - Zip Code:32046-8281
Practice Address - Country:US
Practice Address - Phone:904-845-3574
Practice Address - Fax:904-845-7418
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-21
Last Update Date:2019-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QR1300X
FLARNP1440112363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural HealthGroup - Single Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
108909Medicare Oscar/Certification