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	207R00000X	Internal Medicine Physician

General Provider Information

NPI Number	:	1851063192
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	:	805 HIGHWAY 22
Second Line	:
City	:	WEWAHITCHKA
State	:	FL
Zip	:	32465-3237
Country	:	US
Telephone Number	:	850-568-1053
Fax Number	:	850-229-5671

Authorized Official
Title or Position	:	MANAGED CARE MANAGER
Name	:	MIRANDA HEMM
Credential	:
Telephone Number	:	850-568-1053

Provider Enumeration Date	:	10/05/2021
Last Update Date	:	10/05/2021

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Directions to “ASCENSION SACRED HEART GULF ” Practice Location

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