Provider Demographics
NPI:1639261175
Name:DESOTO MEMORIAL HOSPITAL INC
Entity Type:Organization
Organization Name:DESOTO MEMORIAL HOSPITAL INC
Other - Org Name:DESOTO MEMORIAL CENTER FOR FAMILY HEALTH
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:VINCENT
Authorized Official - Middle Name:A
Authorized Official - Last Name:SICA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:863-494-8403
Mailing Address - Street 1:888 N ROBERTS AVE
Mailing Address - Street 2:
Mailing Address - City:ARCADIA
Mailing Address - State:FL
Mailing Address - Zip Code:34266-9580
Mailing Address - Country:US
Mailing Address - Phone:863-494-8401
Mailing Address - Fax:863-491-4328
Practice Address - Street 1:888 N ROBERTS AVE
Practice Address - Street 2:
Practice Address - City:ARCADIA
Practice Address - State:FL
Practice Address - Zip Code:34266-9580
Practice Address - Country:US
Practice Address - Phone:863-494-8401
Practice Address - Fax:863-491-4328
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-29
Last Update Date:2011-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL4218261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL00746OtherMEDICARE
FL252217900Medicaid
FL660074300Medicaid
FL00746OtherMEDICARE