Provider Demographics
NPI:1982719803
Name:DESOTO MEMORIAL HOSPITAL INC
Entity Type:Organization
Organization Name:DESOTO MEMORIAL HOSPITAL INC
Other - Org Name:DESOTO MEMORIAL HOSPITAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:VINCENT
Authorized Official - Middle Name:A
Authorized Official - Last Name:SICA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:863-494-8403
Mailing Address - Street 1:900 N ROBERTS AVE
Mailing Address - Street 2:
Mailing Address - City:ARCADIA
Mailing Address - State:FL
Mailing Address - Zip Code:34266-8765
Mailing Address - Country:US
Mailing Address - Phone:863-494-3535
Mailing Address - Fax:863-491-4328
Practice Address - Street 1:900 N ROBERTS AVE
Practice Address - Street 2:
Practice Address - City:ARCADIA
Practice Address - State:FL
Practice Address - Zip Code:34266-8765
Practice Address - Country:US
Practice Address - Phone:863-494-3535
Practice Address - Fax:863-491-4328
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-20
Last Update Date:2010-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL4218282NR1301X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282NR1301XHospitalsGeneral Acute Care HospitalRural
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL057132600Medicaid
FL99545OtherMEDICARE
FL010192300Medicaid
FL100175Medicare ID - Type Unspecified