Healthcare Provider Details

I. General information

NPI: 1356868541
Provider Name (Legal Business Name): TALLAHASSEE MEMORIAL HEALTHCARE INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/28/2017
Last Update Date: 01/09/2025
Certification Date: 01/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2619 CENTENNIAL BLVD STE 102
TALLAHASSEE FL
32308-0590
US

IV. Provider business mailing address

1607 SAINT JAMES CT STE 1
TALLAHASSEE FL
32308-5352
US

V. Phone/Fax

Practice location:
  • Phone: 850-431-2875
  • Fax:
Mailing address:
  • Phone: 850-431-7021
  • Fax: 850-431-6975

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number4080
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State

VIII. Authorized Official

Name: JENNIFER PARKS
Title or Position: PRESIDENT
Credential:
Phone: 850-431-6234