Healthcare Provider Details

I. General information

NPI: 1992375935
Provider Name (Legal Business Name): SANTA ROSA HMA PHYSICIAN MANAGEMENT LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/01/2021
Last Update Date: 03/16/2022
Certification Date: 03/16/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4944 HIGHWAY 90
PACE FL
32571-1413
US

IV. Provider business mailing address

PO BOX 689022
FRANKLIN TN
37068-9022
US

V. Phone/Fax

Practice location:
  • Phone: 850-981-4000
  • Fax: 850-994-7883
Mailing address:
  • Phone: 615-465-7211
  • Fax: 615-628-6877

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

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