Provider Demographics
NPI:1770647620
Name:TALLAHASSEE MEMORIAL HEALTHCARE INC
Entity Type:Organization
Organization Name:TALLAHASSEE MEMORIAL HEALTHCARE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBIN
Authorized Official - Middle Name:L
Authorized Official - Last Name:MOSS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:850-431-6256
Mailing Address - Street 1:1607 SAINT JAMES CT STE 1
Mailing Address - Street 2:
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32308-5352
Mailing Address - Country:US
Mailing Address - Phone:850-431-7021
Mailing Address - Fax:850-431-6975
Practice Address - Street 1:1301 HODGES DR
Practice Address - Street 2:
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32308-4614
Practice Address - Country:US
Practice Address - Phone:850-431-3456
Practice Address - Fax:850-431-6403
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:TALLAHASSEE MEMORIAL HEALTHCARE INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-12-21
Last Update Date:2019-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL207Q00000X, 207V00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL060409700Medicaid
FL99325OtherBCBS GROUP NUMBER
FL100135Medicare Oscar/Certification
FL99325OtherBCBS GROUP NUMBER