Provider Demographics
NPI:1710319413
Name:HOLY CROSS HOSPITAL, INC
Entity Type:Organization
Organization Name:HOLY CROSS HOSPITAL, INC
Other - Org Name:HOLY CROSS CLINIC SERVICES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:KENT
Authorized Official - Middle Name:MARTIN
Authorized Official - Last Name:MATHISEN
Authorized Official - Suffix:
Authorized Official - Credentials:MHA
Authorized Official - Phone:954-764-6646
Mailing Address - Street 1:PO BOX 70700
Mailing Address - Street 2:
Mailing Address - City:FT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33307-0700
Mailing Address - Country:US
Mailing Address - Phone:954-229-4702
Mailing Address - Fax:954-229-4705
Practice Address - Street 1:1115 S FEDERAL HWY
Practice Address - Street 2:
Practice Address - City:FT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33316-1256
Practice Address - Country:US
Practice Address - Phone:954-764-6646
Practice Address - Fax:954-764-6234
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:HOLY CROSS HOSPITAL, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-08-05
Last Update Date:2013-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care
No207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical ServicesGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL010018800Medicaid
FL100073Medicare PIN