NPIMap

Organization Active NPI

Northwest Florida Healthcare, Inc.

Doing business as Vernon Clinic - Northwest Florida Community Hospital

  • Family Medicine Physician
  • Vernon, FL
National Provider Identifier
1134422470
Registry record updated Nov 25, 2024
On this page

Key facts

NPPES NPI Registry
Primary specialty
Family Medicine PhysicianTaxonomy code 207Q00000X
License
4005 Issued in FL
Legal business name
NORTHWEST FLORIDA HEALTHCARE, INC.
Doing business as
Vernon Clinic - Northwest Florida Community Hospital
Practice address
3250 Main St
Vernon, FL 32462
Phone
(850) 535-2096
NPI assigned
Dec 8, 2010
Last updated
Nov 25, 2024By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Nov 25, 2024

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Steven Lisenby
Title
Chief Financial Officer
Phone
(850) 415-8107

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Family Medicine Physician 207Q00000X 4005 FL Primary

Addresses

Primary practice location

3250 Main St
Vernon, FL 32462

Mailing address

3250 Main St
Vernon, FL 32462-2223
Phone (850) 535-2096

Other names 1

  • Vernon Clinic - Northwest Florida Community Hospital Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in FL

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20110718000120 FL Part A Provider - Rural Health Clinic 2668363771 Practice locations: Vernon, FL

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1134422470. Details of each certification follow.

Rural health clinic certification: CCN 103450

Legal name
NORTHWEST FLORIDA HEALTHCARE, INC.
Certification status
Active
Provider type (POS)
Rural health clinic
Participating since
Feb 6, 2012
Last certification
Jul 23, 2024
Ownership / control type
1B
Organization structure
CorporationProprietary
Incorporated
Sep 22, 2003 in FL
Enrollment address
3250 Main St
Vernon, FL 32462-2223
Related CCNs
101308

Facilities connected through Provider of Services related, parent or unit certification numbers.

Other NPIs with the same Medicare PAC ID 7

NPIs whose Medicare enrollments share a PECOS associate control ID (the same enrolled entity).

Laboratory certificates & supplier records

Derived by NPIMap

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

CLIA numberLaboratoryCertificateExpires
10D2036672Northwest Florida Community Hospital3250 Main St, Vernon, FL 32462Certificate of waiverFeb 9, 2028

National Provider Directory

National Provider Directory
Tax ID family
Northwest Florida Healthcare Inc10 organizations share this tax ID, including this one

Other organizations with this tax ID 9

Organizations that report the same tax identification number in the National Provider Directory.

Locations

3250 Main St
Vernon, FL 32462
Phone (850) 535-2096

Ownership & related parties

All disclosed owners & managing parties 4

As disclosed on the Medicare enrollment (CMS All Owners files). Individuals include officers, directors and managing employees, who may not hold ownership.

NameRoleSinceShare
Northwest Florida Healthcare, Inc. Organization, Chipley, FL 5% Or Greater Direct Ownership Interest Jun 1, 2011
Ira Smedra Individual Corporate OfficerPresident Dec 21, 2012
Steven Lisenby Individual Corporate OfficerChief Financial Officer Sep 21, 2020
Michael Andrew Kozar Individual Contracted Managing EmployeeCeo Jan 4, 2016
Corporate OfficerCeo Jan 4, 2016

Owners & managing parties with NPI records 7

Owners and managing parties disclosed on this facility’s Medicare enrollment that are themselves Medicare-enrolled.

All facility ownership & control disclosures 3

Facilities whose Medicare enrollment lists this provider’s PECOS associate ID as an owner or managing party.

FacilityTypeRoleSince
Family Healthcare of ChipleyChipley, FL, CCN 103995 Rural health clinic 5% Or Greater Direct Ownership Interest (100%) May 1, 2016
Graceville Clinic - Northwest Florida Community HospitalGraceville, FL, CCN 103457 Rural health clinic 5% Or Greater Direct Ownership Interest (100%) Oct 1, 2017
Bailey Family Practice - Northwest Florida Community HospitalBonifay, FL, CCN 108501 Rural health clinic 5% Or Greater Direct Ownership Interest (100%) Jul 15, 2019

Owned or controlled facilities with NPI records 3

Facilities whose Medicare enrollment lists this provider as an owner, officer, director or managing party.

Facilities with the same owner 3

Facilities that share an organizational owner with 5% or greater ownership or operational control.

Practitioners & affiliated clinicians

Practitioners 1

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1291766400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1732492800000",
    "number": "1134422470",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "3250 MAIN ST",
            "city": "VERNON",
            "state": "FL",
            "postal_code": "324622223",
            "telephone_number": "850-535-2096"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "3250 MAIN ST",
            "city": "VERNON",
            "state": "FL",
            "postal_code": "32462",
            "telephone_number": "850-535-2096"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "NORTHWEST FLORIDA HEALTHCARE, INC.",
        "organizational_subpart": "NO",
        "enumeration_date": "2010-12-08",
        "last_updated": "2024-11-25",
        "certification_date": "2024-11-25",
        "status": "A",
        "authorized_official_last_name": "LISENBY",
        "authorized_official_first_name": "STEVEN",
        "authorized_official_title_or_position": "CHIEF FINANCIAL OFFICER",
        "authorized_official_telephone_number": "850-415-8107"
    },
    "taxonomies": [
        {
            "code": "207Q00000X",
            "taxonomy_group": "",
            "desc": "Family Medicine",
            "state": "FL",
            "license": "4005",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Vernon Clinic - Northwest Florida Community Hospital",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Vernon, FL

Sources for this page

Verify at the official NPI Registry.