Provider Demographics
NPI:1154729549
Name:ST. VINCENT'S MEDICAL CENTER - CLAY COUNTY, INC
Entity type:Organization
Organization Name:ST. VINCENT'S MEDICAL CENTER - CLAY COUNTY, INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:D. BLAINE
Authorized Official - Middle Name:
Authorized Official - Last Name:CLAYPOOL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:904-602-1151
Mailing Address - Street 1:1658 ST VINCENTS WAY
Mailing Address - Street 2:SUITE 300
Mailing Address - City:MIDDLEBURG
Mailing Address - State:FL
Mailing Address - Zip Code:32068-8446
Mailing Address - Country:US
Mailing Address - Phone:904-276-5100
Mailing Address - Fax:904-276-5393
Practice Address - Street 1:1658 ST VINCENTS WAY
Practice Address - Street 2:SUITE 300
Practice Address - City:MIDDLEBURG
Practice Address - State:FL
Practice Address - Zip Code:32068-8446
Practice Address - Country:US
Practice Address - Phone:904-276-5100
Practice Address - Fax:904-276-5393
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ST. VINCENT'S MEDICAL CENTER - CLAY COUNTY, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-12-17
Last Update Date:2014-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME49977207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL10-0321Medicare PIN