Provider Demographics
NPI:1457399982
Name:DOCTORS MEMORIAL HOSPITAL INC
Entity Type:Organization
Organization Name:DOCTORS MEMORIAL HOSPITAL INC
Other - Org Name:DMH FAMILY PRACTICE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CLINIC MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:KAREN
Authorized Official - Middle Name:
Authorized Official - Last Name:TIDWELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:850-223-5409
Mailing Address - Street 1:555 N BYRON BUTLER PKWY
Mailing Address - Street 2:
Mailing Address - City:PERRY
Mailing Address - State:FL
Mailing Address - Zip Code:32347-2315
Mailing Address - Country:US
Mailing Address - Phone:850-223-5400
Mailing Address - Fax:850-223-5401
Practice Address - Street 1:555 N BYRON BUTLER PKWY
Practice Address - Street 2:
Practice Address - City:PERRY
Practice Address - State:FL
Practice Address - Zip Code:32347-2315
Practice Address - Country:US
Practice Address - Phone:850-223-5400
Practice Address - Fax:850-223-5401
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-04
Last Update Date:2012-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL660124300261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL10D079975OtherCLIA
FL103441Medicare ID - Type Unspecified
FL10D079975OtherCLIA