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Organization Active NPI

Tallahassee Memorial Healthcare Inc

  • Rural Health Clinic/Center
  • Monticello, FL
National Provider Identifier
1649229402
Registry record updated Jan 28, 2019
On this page

Key facts

NPPES NPI Registry
Primary specialty
Rural Health Clinic/CenterTaxonomy code 261QR1300X
Legal business name
TALLAHASSEE MEMORIAL HEALTHCARE INC
Practice address
1549 S Jefferson St
Monticello, FL 32344-1651
Phone
(850) 997-0707
Fax
(850) 997-6833
NPI assigned
May 9, 2006
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jan 28, 2019

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

Authorized official

Name
Mr. Robin L Moss
Title
Executive Director
Phone
(850) 431-6256

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Family Medicine PhysicianGroup: 193400000X SINGLE SPECIALTY GROUP 207Q00000X
Rural Health Clinic/Center 261QR1300X FL Primary

Addresses

Primary practice location

1549 S Jefferson St
Monticello, FL 32344-1651

Mailing address

1607 Saint James CT Ste 1
Tallahassee, FL 32308-5352
Phone (850) 431-7021

Other identifiers 3

IdentifierTypeStateIssuer
660037901MedicaidFL
24766EOtherFLBCBS GROUP NUMBER
375270408MedicaidFL

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in FL2 enrollments

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20031222000279 FL Part B Supplier - Clinic/Group Practice 6103724778 Receives reassigned benefits from 702 practitioners
39 other NPIs on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Tallahassee, FL; Blountstown, FL; Chipley, FL; Crawfordville, FL; Madison, FL; Marianna, FL; Monticello, FL; Panama City Beach, FL…
O20100315000255 FL Part A Provider - Rural Health Clinic 6103724778 Practice locations: Monticello, FL

Rural health clinic certification: CCN 103409

Legal name
TALLAHASSEE MEMORIAL HEALTHCARE INC
Doing business as
TALLAHASSEE MEMORIAL FAMILY MEDICINE MONTICELLO
Certification status
Active
Provider type (POS)
Rural health clinic
Participating since
Jul 10, 1995
Last certification
Dec 12, 2024
Ownership / control type
2B
Organization structure
CorporationProprietary
Incorporated
Jun 29, 1979 in FL
Enrollment address
1549 Jefferson St S
Monticello, FL 32344-1717
Related CCNs
100135

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

Other NPIs with the same Medicare PAC ID 10

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

Other NPIs on the same Medicare enrollment 39

NPIs listed together on one Medicare enrollment, typically parts of the same organization.

View all 39

National Provider Directory

National Provider Directory

Locations

1306 Thomasville Rd
Tallahassee, FL 32303

Ownership & related parties

All disclosed owners & managing parties 27

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

NameRoleSinceShare
James S Killius Individual Corporate DirectorDirector Oct 1, 2013
Avery D McKnight Individual Corporate DirectorDirector Oct 1, 2012
Warren E Jones Individual Corporate OfficerChief Communications Officer Mar 8, 2004
W-2 Managing EmployeeChief Communications Officer Mar 8, 2004
Jason Moore Individual Corporate OfficerChief Operating Officer Jul 7, 2008
W-2 Managing EmployeeChief Operating Officer Jul 7, 2008
Glenda Thornton Individual Corporate OfficerChair Oct 1, 2013
Corporate DirectorDirector Oct 1, 2006
William Giudice Individual Corporate OfficerChief Financial Officer Oct 1, 1986
W-2 Managing EmployeeChief Financial Officer Aug 1, 1983
Paula S Fortunas Individual Corporate OfficerChief Development Officer Jan 19, 2004
W-2 Managing EmployeeChief Development Officer Jan 19, 2004
Alma Littles Individual Corporate OfficerTreasurer Oct 1, 2013
Corporate DirectorDirector Oct 1, 2008
Robin L Moss Individual Corporate Director Dec 10, 2009
W-2 Managing Employee Dec 10, 2009
Donald W Lindsey Individual Corporate OfficerChief Information Officer Mar 2, 2008
W-2 Managing EmployeeChief Information Officer Mar 2, 2008
Dean Watson Individual Corporate OfficerChief Medical Officer Jan 3, 2010
W-2 Managing EmployeeChief Medical Officer Jan 3, 2010
Joseph L Camps Individual Corporate DirectorDirector Sep 24, 2004
Robert L Moore Individual Corporate OfficerChief Human Resources Officer Apr 14, 2013
W-2 Managing EmployeeChief Human Resources Officer Apr 14, 2013
Erin Ennis Individual Corporate DirectorDirector Oct 1, 2005
George M Obryant Individual Corporate OfficerPresident/Ceo Jul 14, 2003
W-2 Managing EmployeePresident/Ceo Jul 14, 2003
Andrew M Wong Individual Corporate DirectorDirector Oct 1, 2013
Cynthia Blair Individual Corporate OfficerChief Improvement Officer May 23, 2005
W-2 Managing EmployeeChief Improvement Officer May 23, 2005
Christopher S Rumana Individual Corporate DirectorDirector Oct 1, 2011
Susie Busch Transou Individual Corporate OfficerSecretary Oct 1, 2013
Corporate DirectorDirector Oct 1, 2007
Laurie Dozier Individual Corporate DirectorDirector Oct 1, 2005
Frank Gredler Individual Corporate OfficerChair Elect Oct 1, 2013
Corporate DirectorDirector Oct 1, 2006
Rick Moore Individual Corporate DirectorDirector Oct 1, 2007
Martha W Barnett Individual Corporate DirectorDirector Oct 1, 2012
Steven L Evans Individual Corporate DirectorDirector Oct 1, 2012
Barbara E Alford Individual Corporate OfficerChief Nursing Officer Mar 10, 2013
W-2 Managing EmployeeChief Nursing Officer Mar 10, 2013
Gary E Winchester Individual Corporate DirectorDirector Oct 1, 2011
Winston Howell Individual Corporate DirectorDirector Oct 1, 2013

Owners & managing parties with NPI records 6

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

All facility ownership & control disclosures 1

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

FacilityTypeRoleSince
Tallahassee Memorial Behavior Health CenterTallahassee, FL, CCN 10S135 Hospital Operational/Managerial Control (100%) Jun 29, 1979

Owned or controlled facilities with NPI records 1

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

Practitioners & affiliated clinicians

Practitioners 498

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

View all 498

NPI Registry JSON

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

{
    "created_epoch": "1147132800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1548633600000",
    "number": "1649229402",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1607 SAINT JAMES CT STE 1",
            "city": "TALLAHASSEE",
            "state": "FL",
            "postal_code": "323085352",
            "telephone_number": "850-431-7021",
            "fax_number": "850-431-6975"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1549 S JEFFERSON ST",
            "city": "MONTICELLO",
            "state": "FL",
            "postal_code": "323441651",
            "telephone_number": "850-997-0707",
            "fax_number": "850-997-6833"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "TALLAHASSEE MEMORIAL HEALTHCARE INC",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-05-09",
        "last_updated": "2019-01-28",
        "status": "A",
        "authorized_official_last_name": "MOSS",
        "authorized_official_first_name": "ROBIN",
        "authorized_official_middle_name": "L",
        "authorized_official_title_or_position": "EXECUTIVE DIRECTOR",
        "authorized_official_telephone_number": "850-431-6256",
        "authorized_official_name_prefix": "Mr."
    },
    "taxonomies": [
        {
            "code": "207Q00000X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Family Medicine",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "261QR1300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Rural Health",
            "state": "FL",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "660037901",
            "state": "FL"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "BCBS GROUP NUMBER",
            "identifier": "24766E",
            "state": "FL"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "375270408",
            "state": "FL"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Monticello, FL

Sources for this page

Verify at the official NPI Registry.