Healthcare Provider Details

I. General information

NPI: 1821031683
Provider Name (Legal Business Name): SOUTH TITUSVILLE MEDICAL CENTER INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/13/2006
Last Update Date: 10/22/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7455 S US HIGHWAY 1
TITUSVILLE FL
32780-8115
US

IV. Provider business mailing address

7455 S US HIGHWAY 1
TITUSVILLE FL
32780-8115
US

V. Phone/Fax

Practice location:
  • Phone: 321-264-2100
  • Fax: 321-264-2485
Mailing address:
  • Phone: 321-264-2100
  • Fax: 321-264-2485

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License NumberME0051997
License Number StateFL

VIII. Authorized Official

Name: MR. CHARLES A SLATTERY
Title or Position: OWNER/CEO
Credential: M.D.
Phone: 321-264-2100