Provider Demographics
NPI:1154392686
Name:FLORIDA DEPARTMENT OF HEALTH
Entity type:Organization
Organization Name:FLORIDA DEPARTMENT OF HEALTH
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:ANGELA
Authorized Official - Middle Name:M
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:BS, MHA
Authorized Official - Phone:239-461-6150
Mailing Address - Street 1:83 PONDELLA RD
Mailing Address - Street 2:
Mailing Address - City:NORTH FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33903-4411
Mailing Address - Country:US
Mailing Address - Phone:239-461-6119
Mailing Address - Fax:239-461-6153
Practice Address - Street 1:2295 VICTORIA AVE FL 2
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33901-3884
Practice Address - Country:US
Practice Address - Phone:239-461-6119
Practice Address - Fax:239-461-6153
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FLORIDA DEPARTMENT OF HEALTH
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-02-01
Last Update Date:2019-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251K00000XAgenciesPublic Health or Welfare
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL0279463Medicaid
FL115135OtherAMERIGROUP FL INC
FL77035Medicare ID - Type Unspecified