Provider Demographics
NPI:1801235445
Name:SANTA ROSA HMA PHYSICIAN MANAGEMENT, LLC
Entity type:Organization
Organization Name:SANTA ROSA HMA PHYSICIAN MANAGEMENT, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:SENIOR DIRECTOR PROVIDER ENROLLMENT
Authorized Official - Prefix:MS
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:L
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-465-3334
Mailing Address - Street 1:5811 PELICAN BAY BLVD
Mailing Address - Street 2:500
Mailing Address - City:NAPLES
Mailing Address - State:FL
Mailing Address - Zip Code:34108-2704
Mailing Address - Country:US
Mailing Address - Phone:239-552-3514
Mailing Address - Fax:239-592-0438
Practice Address - Street 1:1929 ORTEGA ST
Practice Address - Street 2:
Practice Address - City:NAVARRE
Practice Address - State:FL
Practice Address - Zip Code:32566-4111
Practice Address - Country:US
Practice Address - Phone:850-396-8048
Practice Address - Fax:850-936-8049
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:HEALTH MANAGEMENT ASSOCIATES
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-06-17
Last Update Date:2022-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLAE879Medicare PIN