NPIMap

Organization Active NPI

Doctors Memorial Hospital Inc

Doing business as DMH Family Medicine

  • Rural Health Clinic/Center
  • Mayo, FL
National Provider Identifier
1487613121
Registry record updated Nov 27, 2012
On this page

Key facts

NPPES NPI Registry
Primary specialty
Rural Health Clinic/CenterTaxonomy code 261QR1300X
License
660123500 Issued in FL
Legal business name
DOCTORS MEMORIAL HOSPITAL INC
Doing business as
DMH Family Medicine
Practice address
113 E Main St
Mayo, FL 32066-4808
Phone
(386) 294-2475
Fax
(386) 294-2478
NPI assigned
Mar 21, 2006
Last updated
Nov 27, 2012By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Nov 27, 2012

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

Authorized official

Name
Ms. Karen Tidwell
Title
Clinic Manager
Phone
(850) 223-5409

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Rural Health Clinic/Center 261QR1300X 660123500 FL Primary

Addresses

Primary practice location

113 E Main St
Mayo, FL 32066-4808

Mailing address

117 SW Virginia Cir
Mayo, FL 32066-4065
Phone (386) 294-2475

Other identifiers 3

IdentifierTypeStateIssuer
10D0961929OtherCLIA
660123500MedicaidFL
24274COtherBCBS

Other names 1

  • DMH Family Medicine Doing business as

Medicare participation

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

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20060210000200 FL Part A Provider - Rural Health Clinic 5092614503 Practice locations: Mayo, FL

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1487613121. Details of each certification follow.

Rural health clinic certification: CCN 103440

Legal name
DOCTORS MEMORIAL HOSPITAL INC
Doing business as
DMH FAMILY MEDICINE
Certification status
Active
Provider type (POS)
Rural health clinic
Participating since
Oct 5, 2000
Last certification
Feb 10, 2025
Ownership / control type
For profit – corporation
Organization structure
CorporationNon-profit
Incorporated
May 15, 1992 in FL
Enrollment address
117 SW Virginia Circle
Mayo, FL 32066-4064
Related CCNs
101314

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

Other NPIs with the same Medicare PAC ID 5

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

National Provider Directory

National Provider Directory
Tax ID family
Pediatric Internal Medi10 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

333 N Byron Butler Pkwy
Fl Second
Perry, FL 32347

Ownership & related parties

All disclosed owners & managing parties 2

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

NameRoleSinceShare
Sara Grambling Individual Corporate Director Jul 10, 2008
W-2 Managing Employee Jul 10, 2008
Karen Tidwell Individual Corporate DirectorDirector Clinic Operations Jun 13, 2013
W-2 Managing EmployeeClinic Director Oct 4, 2010

Practitioners & affiliated clinicians

Practitioners 6

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": "1142899200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1353974400000",
    "number": "1487613121",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "117 SW VIRGINIA CIR",
            "city": "MAYO",
            "state": "FL",
            "postal_code": "320664065",
            "telephone_number": "386-294-2475"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "113 E MAIN ST",
            "city": "MAYO",
            "state": "FL",
            "postal_code": "320664808",
            "telephone_number": "386-294-2475",
            "fax_number": "386-294-2478"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "DOCTORS MEMORIAL HOSPITAL INC",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-03-21",
        "last_updated": "2012-11-27",
        "status": "A",
        "authorized_official_last_name": "TIDWELL",
        "authorized_official_first_name": "KAREN",
        "authorized_official_title_or_position": "CLINIC MANAGER",
        "authorized_official_telephone_number": "850-223-5409",
        "authorized_official_name_prefix": "Ms."
    },
    "taxonomies": [
        {
            "code": "261QR1300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Rural Health",
            "state": "FL",
            "license": "660123500",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "CLIA",
            "identifier": "10D0961929",
            "state": null
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "660123500",
            "state": "FL"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "BCBS",
            "identifier": "24274C",
            "state": null
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "DMH Family Medicine",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Mayo, FL

Sources for this page

Verify at the official NPI Registry.