Provider Demographics
NPI:1962497198
Name:MELBOURNE HMA, LLC
Entity Type:Organization
Organization Name:MELBOURNE HMA, LLC
Other - Org Name:WUESTHOFF MEDICAL CENTER - MELBOURNE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:AUTHORIZED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:LAURIE
Authorized Official - Middle Name:
Authorized Official - Last Name:HOLTSFORD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-465-7466
Mailing Address - Street 1:250 N WICKHAM RD
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32935-8625
Mailing Address - Country:US
Mailing Address - Phone:321-752-1200
Mailing Address - Fax:
Practice Address - Street 1:250 N WICKHAM RD
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32935-8625
Practice Address - Country:US
Practice Address - Phone:321-752-1200
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-14
Last Update Date:2014-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL4468282N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282N00000XHospitalsGeneral Acute Care Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL010320900Medicaid
FL100291Medicare Oscar/Certification