Provider Demographics
NPI:1952351306
Name:FLORIDA COMMUNITY HEALTH CENTERS INC
Entity Type:Organization
Organization Name:FLORIDA COMMUNITY HEALTH CENTERS INC
Other - Org Name:LAKESHORE MEDICAL - ADULTS
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT & CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:F
Authorized Official - Last Name:GERVASI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:561-844-9443
Mailing Address - Street 1:5827 CORPORATE WAY
Mailing Address - Street 2:
Mailing Address - City:WEST PALM BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33407-2000
Mailing Address - Country:US
Mailing Address - Phone:561-844-9443
Mailing Address - Fax:561-844-1013
Practice Address - Street 1:1100 N PARROTT AVE
Practice Address - Street 2:
Practice Address - City:OKEECHOBEE
Practice Address - State:FL
Practice Address - Zip Code:34972-2129
Practice Address - Country:US
Practice Address - Phone:863-763-7481
Practice Address - Fax:863-763-5920
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-10
Last Update Date:2016-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty
No261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)Group - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL029574407Medicaid
FL029574406Medicaid
FL029574406Medicaid
FL00589CMedicare PIN