=====================================================
General NPI Number Information
=====================================================
NPI Number | 1851837538
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ORLANDO VA MEDICAL CENTER
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/18/2017
-----------------------------------------------------
Last Update Date | 01/18/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5201 RAYMOND ST
-----------------------------------------------------
City | ORLANDO
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32803-8208
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 422-637-1600
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6090 HONEYWOOD WAY
-----------------------------------------------------
City | LAKE WORTH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33463-6715
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MEDICAL CENTER DIRECTOR
-----------------------------------------------------
Name | TIMOTHY W LIEZERT
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 42263714000
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 282E00000X
-----------------------------------------------------
Taxonomy Name | Long Term Care Hospital
-----------------------------------------------------
License Number | PS53630
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------