Provider Demographics
NPI:1790728657
Name:DOCTORS MEMORIAL HOSPITAL INC
Entity Type:Organization
Organization Name:DOCTORS MEMORIAL HOSPITAL INC
Other - Org Name:DMH INTERNAL MEDICINE
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 1:402 E ASH ST
Practice Address - Street 2:
Practice Address - City:PERRY
Practice Address - State:FL
Practice Address - Zip Code:32347-2105
Practice Address - Country:US
Practice Address - Phone:850-584-0600
Practice Address - Fax:580-584-0602
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-14
Last Update Date:2008-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL660138300261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL660138300Medicaid
10D0961933OtherCLIA
103442Medicare ID - Type Unspecified