=====================================================
General NPI Number Information
=====================================================
NPI Number | 1447555743
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TALLAHASSEE MEMORIAL HEALTHCARE INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/18/2011
-----------------------------------------------------
Last Update Date | 01/09/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4230 HOSPITAL DR STE 202
-----------------------------------------------------
City | MARIANNA
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32446-1955
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 850-482-2205
-----------------------------------------------------
Fax | 850-482-2364
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1607 SAINT JAMES CT STE 1
-----------------------------------------------------
City | TALLAHASSEE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32308-5352
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 850-431-7021
-----------------------------------------------------
Fax | 850-431-6975
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | JENNIFER PARKS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 850-431-6234
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RC0000X
-----------------------------------------------------
Taxonomy Name | Cardiovascular Disease Physician
-----------------------------------------------------
License Number | 4080
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------