Provider Demographics
NPI:1639117237
Name:DOCTORS MEMORIAL HOSPITAL INC
Entity Type:Organization
Organization Name:DOCTORS MEMORIAL HOSPITAL INC
Other - Org Name:DMH PEDIATRICS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:SARA
Authorized Official - Middle Name:
Authorized Official - Last Name:GRAMBLING
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:850-584-0609
Mailing Address - Street 1:333 N BYRON BUTLER PKWY
Mailing Address - Street 2:
Mailing Address - City:PERRY
Mailing Address - State:FL
Mailing Address - Zip Code:32347-2300
Mailing Address - Country:US
Mailing Address - Phone:850-584-0609
Mailing Address - Fax:850-584-0689
Practice Address - Street 1:1211 N CENTER ST
Practice Address - Street 2:
Practice Address - City:PERRY
Practice Address - State:FL
Practice Address - Zip Code:32347-2037
Practice Address - Country:US
Practice Address - Phone:850-584-2141
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-04
Last Update Date:2008-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
10D0961931OtherCLIA
FL660099900Medicaid
FL660099900Medicaid