Provider Demographics
NPI:1821031683
Name:SOUTH TITUSVILLE MEDICAL CENTER INC
Entity Type:Organization
Organization Name:SOUTH TITUSVILLE MEDICAL CENTER INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:A
Authorized Official - Last Name:SLATTERY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:321-264-2100
Mailing Address - Street 1:7455 S US HIGHWAY 1
Mailing Address - Street 2:
Mailing Address - City:TITUSVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32780-8115
Mailing Address - Country:US
Mailing Address - Phone:321-264-2100
Mailing Address - Fax:321-264-2485
Practice Address - Street 1:7455 S US HIGHWAY 1
Practice Address - Street 2:
Practice Address - City:TITUSVILLE
Practice Address - State:FL
Practice Address - Zip Code:32780-8115
Practice Address - Country:US
Practice Address - Phone:321-264-2100
Practice Address - Fax:321-264-2485
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-13
Last Update Date:2014-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0051997261QH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL062108100Medicaid
FLD20979Medicare UPIN
FL062108100Medicaid