Provider Demographics
NPI:1952441511
Name:TIDEWELL HOSPICE AND PALLIATIVE CARE
Entity Type:Organization
Organization Name:TIDEWELL HOSPICE AND PALLIATIVE CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:DAVID
Authorized Official - Last Name:FLEECE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:941-552-7525
Mailing Address - Street 1:5955 RAND BLVD
Mailing Address - Street 2:
Mailing Address - City:SARASOTA
Mailing Address - State:FL
Mailing Address - Zip Code:34238-5160
Mailing Address - Country:US
Mailing Address - Phone:941-552-7517
Mailing Address - Fax:941-552-7518
Practice Address - Street 1:5955 RAND BLVD
Practice Address - Street 2:
Practice Address - City:SARASOTA
Practice Address - State:FL
Practice Address - Zip Code:34238-5160
Practice Address - Country:US
Practice Address - Phone:941-552-7517
Practice Address - Fax:941-552-7518
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:TIDEWELL HOSPICE AND PALLIATIVE CARE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-02-06
Last Update Date:2023-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL5028096174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLK8371Medicare ID - Type UnspecifiedMEDICARE PART B PROVIDER