Provider Demographics
NPI:1891874707
Name:FLORIDA DEPARTMENT OF HEALTH
Entity Type:Organization
Organization Name:FLORIDA DEPARTMENT OF HEALTH
Other - Org Name:, SUWANNEE COUNTY HEALTH DEPARTMENT
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:PAMELA
Authorized Official - Middle Name:
Authorized Official - Last Name:BLACKMON
Authorized Official - Suffix:
Authorized Official - Credentials:RN, BSN, MPH
Authorized Official - Phone:386-362-2708
Mailing Address - Street 1:PO BOX 268
Mailing Address - Street 2:
Mailing Address - City:BRANFORD
Mailing Address - State:FL
Mailing Address - Zip Code:32008-0268
Mailing Address - Country:US
Mailing Address - Phone:386-935-1133
Mailing Address - Fax:386-935-1362
Practice Address - Street 1:120 SUWANNEE AVE
Practice Address - Street 2:
Practice Address - City:BRANFORD
Practice Address - State:FL
Practice Address - Zip Code:32008
Practice Address - Country:US
Practice Address - Phone:386-935-1133
Practice Address - Fax:386-935-1362
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-02
Last Update Date:2010-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL251K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251K00000XAgenciesPublic Health or Welfare
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL051832800Medicaid
FL051832892Medicaid
FL051832809Medicaid
FL00951Medicare PIN