MEDICARE: TALLAHASSEE MEMORIAL HEALTHCARE INC

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	207Q00000X	Family Medicine Physician
2	261QR1300X	Rural Health Clinic/Center		FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	24766E	OTHER	FL	BCBS GROUP NUMBER
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1649229402
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TALLAHASSEE MEMORIAL HEALTHCARE INC

Provider Business Mailing Address
First Line	:	1607 SAINT JAMES CT STE 1
Second Line	:
City	:	TALLAHASSEE
State	:	FL
Zip	:	32308-5352
Country	:	US
Telephone Number	:	850-431-7021
Fax Number	:	850-431-6975

Provider Business Practice Location Address
First Line	:	1549 S JEFFERSON ST
Second Line	:
City	:	MONTICELLO
State	:	FL
Zip	:	32344-1651
Country	:	US
Telephone Number	:	850-997-0707
Fax Number	:	850-997-6833

Authorized Official
Title or Position	:	EXECUTIVE DIRECTOR
Name	:	MR. ROBIN L MOSS
Credential	:
Telephone Number	:	850-431-6256

Provider Enumeration Date	:	05/09/2006
Last Update Date	:	01/28/2019

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