=====================================================
General NPI Number Information
=====================================================
NPI Number | 1043514656
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ADVENTIST HEALTH SYSTEM/SUNBELT, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/23/2010
-----------------------------------------------------
Last Update Date | 04/20/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 19015 U.S. HIGHWAY 441
-----------------------------------------------------
City | MOUNT DORA
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32757
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 352-383-3484
-----------------------------------------------------
Fax | 352-735-0517
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2600 WESTHALL LANE, BOX 300
-----------------------------------------------------
City | MAITLAND
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32751
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 407-200-2300
-----------------------------------------------------
Fax | 407-200-1365
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT/CEO
-----------------------------------------------------
Name | SCOTT C. BRADY
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 407-200-2300
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 208000000X
-----------------------------------------------------
Taxonomy Name | Pediatrics Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 332900000X
-----------------------------------------------------
Taxonomy Name | Non-Pharmacy Dispensing Site
-----------------------------------------------------
License Number | ME 57207
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 363A00000X
-----------------------------------------------------
Taxonomy Name | Physician Assistant
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #5
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #6
-----------------------------------------------------
Taxonomy Code | 261QU0200X
-----------------------------------------------------
Taxonomy Name | Urgent Care Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------