MEDICARE: DESOTO MEMORIAL HOSPITAL 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	282NR1301X	Rural Acute Care Hospital	4218	FL

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	99545	OTHER	FL	MEDICARE

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
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1982719803
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DESOTO MEMORIAL HOSPITAL INC

Provider Business Mailing Address
First Line	:	900 N ROBERTS AVE
Second Line	:
City	:	ARCADIA
State	:	FL
Zip	:	34266-8765
Country	:	US
Telephone Number	:	863-494-3535
Fax Number	:	863-491-4328

Provider Business Practice Location Address
First Line	:	900 N ROBERTS AVE
Second Line	:
City	:	ARCADIA
State	:	FL
Zip	:	34266-8765
Country	:	US
Telephone Number	:	863-494-3535
Fax Number	:	863-491-4328

Authorized Official
Title or Position	:	CEO
Name	:	MR. VINCENT A SICA
Credential	:
Telephone Number	:	863-494-8403

Provider Enumeration Date	:	08/20/2006
Last Update Date	:	07/12/2010

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