Provider Demographics
NPI:1457623233
Name:ST JOSEPHS HOPSITAL
Entity Type:Organization
Organization Name:ST JOSEPHS HOPSITAL
Other - Org Name:SJN NEONATES
Other - Org Type:Other Name
Authorized Official - Title/Position:VP
Authorized Official - Prefix:MS
Authorized Official - First Name:LYNDA
Authorized Official - Middle Name:
Authorized Official - Last Name:GORKEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:727-281-9390
Mailing Address - Street 1:2995 DREW ST FL 2
Mailing Address - Street 2:
Mailing Address - City:CLEARWATER
Mailing Address - State:FL
Mailing Address - Zip Code:33759-3012
Mailing Address - Country:US
Mailing Address - Phone:727-281-9390
Mailing Address - Fax:813-635-2613
Practice Address - Street 1:4211 VAN DYKE RD
Practice Address - Street 2:
Practice Address - City:LUTZ
Practice Address - State:FL
Practice Address - Zip Code:33558-8002
Practice Address - Country:US
Practice Address - Phone:813-443-2010
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-08
Last Update Date:2020-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL363LN0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LN0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerNeonatalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLPENDINGMedicaid