1861655656 NPI number — JESSIE TRICE COMMUNITY HEALTH SYSTEM INC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1861655656 NPI number — JESSIE TRICE COMMUNITY HEALTH SYSTEM INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
JESSIE TRICE COMMUNITY HEALTH SYSTEM INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
JESSIE TRICE COMMUNITY HEALTH CENTER, INC
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1861655656
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/07/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5607 NW 27TH AVE
Provider Second Line Business Mailing Address:
SUITE 1
Provider Business Mailing Address City Name:
MIAMI
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33142-2826
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
305-805-1700
Provider Business Mailing Address Fax Number:
305-805-1715

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1190 NW 95TH ST
Provider Second Line Business Practice Location Address:
SUITE 100
Provider Business Practice Location Address City Name:
MIAMI
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33150-2063
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
305-637-6400
Provider Business Practice Location Address Fax Number:
305-805-1715
Provider Enumeration Date:
07/02/2008

Additional Information

Authorized Official

Authorized Official Last Name:
NEASMAN
Authorized Official First Name:
ANNIE
Authorized Official Middle Name:
R
Authorized Official Title or Position:
PRESIDENT AND CEO
Authorized Official Telephone Number:
305-805-1700

Provider Taxonomy Codes

  • Taxonomy code: 261QF0400X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 029541804 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 029541805 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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