Provider Demographics
NPI:1285709451
Name:DOCTORS MEMORIAL HOSPITAL INC
Entity type:Organization
Organization Name:DOCTORS MEMORIAL HOSPITAL INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CLINIC MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:KAREN
Authorized Official - Middle Name:
Authorized Official - Last Name:TIDWELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:850-223-5409
Mailing Address - Street 1:333 N BYRON BUTLER PKWY
Mailing Address - Street 2:
Mailing Address - City:PERRY
Mailing Address - State:FL
Mailing Address - Zip Code:32347-2300
Mailing Address - Country:US
Mailing Address - Phone:850-584-8404
Mailing Address - Fax:850-584-3885
Practice Address - Street 1:333 N BYRON BUTLER PKWY
Practice Address - Street 2:
Practice Address - City:PERRY
Practice Address - State:FL
Practice Address - Zip Code:32347-2300
Practice Address - Country:US
Practice Address - Phone:850-584-0860
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-22
Last Update Date:2022-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL275448700Medicaid
36645OtherBCBS
23466WOtherBCBS
FL252009500Medicaid
FL275738900Medicaid
53900OtherBCBS
FL374283100Medicaid
FL279528100Medicaid
24274OtherBCBS
FL250953900Medicaid
41469BOtherBCBS
23466WOtherBCBS
FL275448700Medicaid
FL374283100Medicaid