Provider Demographics
NPI:1184137929
Name:SAINT GEORGE MEDICAL CENTER INC
Entity type:Organization
Organization Name:SAINT GEORGE MEDICAL CENTER INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ERICA
Authorized Official - Middle Name:
Authorized Official - Last Name:GEORGE-SAINTILUS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:850-862-3415
Mailing Address - Street 1:790 BARLEY PORT LN
Mailing Address - Street 2:
Mailing Address - City:FORT WALTON BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32547-5722
Mailing Address - Country:US
Mailing Address - Phone:850-862-3415
Mailing Address - Fax:
Practice Address - Street 1:1118 HOSPITAL RD
Practice Address - Street 2:
Practice Address - City:FORT WALTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:32547-6742
Practice Address - Country:US
Practice Address - Phone:850-862-3415
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-11-15
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME100869207QG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL190605Medicaid