Provider Demographics
NPI:1811991227
Name:HALIFAX HOSPITAL MEDICAL CENTER
Entity type:Organization
Organization Name:HALIFAX HOSPITAL MEDICAL CENTER
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:ERIC
Authorized Official - Middle Name:M
Authorized Official - Last Name:PEBURN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:386-425-4568
Mailing Address - Street 1:303 N CLYDE MORRIS BLVD
Mailing Address - Street 2:
Mailing Address - City:DAYTONA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32114-2709
Mailing Address - Country:US
Mailing Address - Phone:386-425-4000
Mailing Address - Fax:
Practice Address - Street 1:303 N CLYDE MORRIS BLVD
Practice Address - Street 2:
Practice Address - City:DAYTONA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32114-2709
Practice Address - Country:US
Practice Address - Phone:386-254-4000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-13
Last Update Date:2021-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL4181251B00000X, 261QM0801X, 273R00000X, 273Y00000X, 282N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282N00000XHospitalsGeneral Acute Care Hospital
No251B00000XAgenciesCase Management
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No273R00000XHospital UnitsPsychiatric Unit
No273Y00000XHospital UnitsRehabilitation Unit
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL7614799-00Medicaid
FL0101842-00Medicaid
FL0101842-01Medicaid
FL0299481-00Medicaid
FL303OtherBLUE CROSS
FL0101842-04Medicaid
FL303OtherBLUE CROSS
FL0299481-00Medicaid
FL10-S017Medicare Oscar/Certification