Provider Demographics
NPI:1982906582
Name:SPACE COAST MEDICAL CENTER
Entity Type:Organization
Organization Name:SPACE COAST MEDICAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARY
Authorized Official - Middle Name:
Authorized Official - Last Name:HARRISON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:321-269-5533
Mailing Address - Street 1:3550 S WASHINGTON AVE
Mailing Address - Street 2:SUITE 24
Mailing Address - City:TITUSVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32780-8627
Mailing Address - Country:US
Mailing Address - Phone:321-269-5533
Mailing Address - Fax:321-269-3009
Practice Address - Street 1:3550 S WASHINGTON AVE
Practice Address - Street 2:SUITE 24
Practice Address - City:TITUSVILLE
Practice Address - State:FL
Practice Address - Zip Code:32780-8627
Practice Address - Country:US
Practice Address - Phone:321-269-5533
Practice Address - Fax:321-269-3009
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-12-02
Last Update Date:2010-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty