MEDICARE: ASCENSION SACRED HEART GULF

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208600000X	Surgery Physician

General Provider Information

NPI Number	:	1568133486
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ASCENSION SACRED HEART GULF

Provider Business Mailing Address
First Line	:	4205 BELFORT RD STE 4015
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32216-3623
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3871 E HIGHWAY 98
Second Line	:
City	:	PORT ST JOE
State	:	FL
Zip	:	32456-5301
Country	:	US
Telephone Number	:	850-229-5833
Fax Number	:	850-229-5832

Authorized Official
Title or Position	:	ENROLLMENT MANAGER
Name	:	MIRANDA HEMM
Credential	:
Telephone Number	:	850-229-5833

Provider Enumeration Date	:	09/21/2021
Last Update Date	:	09/21/2021

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Directions to “ASCENSION SACRED HEART GULF ” Practice Location

Language	Start Address	Practice Location

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