Provider Demographics
NPI:1659416949
Name:RIVERSIDE GLADES MEDICAL CENTER
Entity Type:Organization
Organization Name:RIVERSIDE GLADES MEDICAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:DONALD
Authorized Official - Last Name:GEAKE
Authorized Official - Suffix:JR
Authorized Official - Credentials:DO
Authorized Official - Phone:863-946-1000
Mailing Address - Street 1:PO BOX 1332
Mailing Address - Street 2:51 AVE J
Mailing Address - City:MOORE HAVEN
Mailing Address - State:FL
Mailing Address - Zip Code:33471-1332
Mailing Address - Country:US
Mailing Address - Phone:863-946-1000
Mailing Address - Fax:863-946-1110
Practice Address - Street 1:51 AVENUE J SW
Practice Address - Street 2:-MAIL NOT DELIVERED TO THIS RURAL ADDRESS
Practice Address - City:MOORE HAVEN
Practice Address - State:FL
Practice Address - Zip Code:33471-1332
Practice Address - Country:US
Practice Address - Phone:863-946-1000
Practice Address - Fax:863-946-1110
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-21
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS7165207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLOS7165OtherMEDICAL LICENSE
FLOS7165OtherMEDICAL LICENSE
FL57-346Medicare ID - Type Unspecified
FLOS7165OtherMEDICAL LICENSE