Healthcare Provider Details

I. General information

NPI: 1093474637
Provider Name (Legal Business Name): SANTA ROSA HMA PHYSICIAN MANAGEMENT LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/10/2021
Last Update Date: 03/16/2022
Certification Date: 03/16/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4225 WOODBINE RD STE G
MILTON FL
32571-8791
US

IV. Provider business mailing address

PO BOX 689022
FRANKLIN TN
37068-9022
US

V. Phone/Fax

Practice location:
  • Phone: 850-994-6575
  • Fax: 850-994-5643
Mailing address:
  • Phone: 615-465-7211
  • Fax: 877-892-9815

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: JENNIFER L JACKSON
Title or Position: SR DIR ONBOARDING & PROV ENROLLMENT
Credential:
Phone: 615-465-3334