MEDICARE: JESSIE TRICE COMMUNITY HEALTH SYSTEM, INC

Medicare Provider Information

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QC1500X	Community Health Clinic/Center
2	251S00000X	Community/Behavioral Health Agency
3	261QF0400X	Federally Qualified Health Center (FQHC)	5143177	FL

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
4	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

NPI Number	:	1689605362
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	JESSIE TRICE COMMUNITY HEALTH SYSTEM, INC

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

Provider Business Practice Location Address
First Line	:	5361 NW 22ND AVE
Second Line	:
City	:	MIAMI
State	:	FL
Zip	:	33142-8035
Country	:	US
Telephone Number	:	305-637-6400
Fax Number	:	305-636-5155

Authorized Official
Title or Position	:	PRESIDENT & CEO
Name	:	RYAN R. HAWKINS
Credential	:
Telephone Number	:	305-805-1700

Provider Enumeration Date	:	07/05/2006
Last Update Date	:	11/26/2024

701 NW 27TH AVE
MIAMI, FL
33125-3012

Practice Phone: 786-744-1900
Practice Fax: 305-760-4141