Provider Demographics
NPI:1558664938
Name:MERIDIAN HEALTH SYSTEMS, INC
Entity Type:Organization
Organization Name:MERIDIAN HEALTH SYSTEMS, INC
Other - Org Name:NONE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ANTHONY
Authorized Official - Middle Name:C
Authorized Official - Last Name:DIKE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:323-434-4626
Mailing Address - Street 1:4127 W 62ND ST
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90043-3612
Mailing Address - Country:US
Mailing Address - Phone:323-434-4626
Mailing Address - Fax:310-693-8082
Practice Address - Street 1:265 CITRUS TOWER BLVD STE 206
Practice Address - Street 2:
Practice Address - City:CLERMONT
Practice Address - State:FL
Practice Address - Zip Code:34711-1908
Practice Address - Country:US
Practice Address - Phone:323-434-1070
Practice Address - Fax:310-693-8082
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-12-07
Last Update Date:2022-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207R00000X
FLME110756261QM1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLME110756OtherFLORIDA HEALTH DEPARTMENT-DIVISION OF MEDICAL QUALITY ASSURANCE