NPIMap

Organization Active NPI

Community Health of South Florida, Inc

  • Federally Qualified Health Center (FQHC)
  • Tavernier, FL
National Provider Identifier
1801219258
Registry record updated Aug 29, 2024
On this page

Key facts

NPPES NPI Registry
Primary specialty
Federally Qualified Health Center (FQHC)Taxonomy code 261QF0400X
Legal business name
COMMUNITY HEALTH OF SOUTH FLORIDA, INC
Practice address
91200 Overseas Hwy
#17
Tavernier, FL 33070-2500
Phone
(305) 253-5100
NPI assigned
Jan 21, 2014
Last updated
Aug 29, 2024By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Aug 29, 2024

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

Authorized official

Name
Mr. Blake Hall
Title
Presdent/Ceo
Phone
(305) 252-4853

Specialties & licenses 3

Specialty (taxonomy)CodeLicenseStatePrimary
Federally Qualified Health Center (FQHC) 261QF0400X NU Primary
General Practice Physician 208D00000X NU
Community/Behavioral Health Agency 251S00000X NU

Addresses

Primary practice location

91200 Overseas Hwy
#17
Tavernier, FL 33070-2500

Mailing address

10300 SW 216 St
Miami, FL 33190-1003
Phone (305) 253-5100

Other identifiers 3

IdentifierTypeStateIssuer
010762301MedicaidFL
010762328MedicaidFL
060303110MedicaidFL

Other names 1

  • Tavernier Community Health Center Other name

Medicare participation

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

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20031118000460 FL Part B Supplier - Clinic/Group Practice 6507770526 Receives reassigned benefits from 147 practitioners
17 other NPIs on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Tavernier, FL; Cutler Bay, FL; South Miami, FL; Perrine, FL; Naranja, FL; Miami, FL; Marathon, FL; Key West, FL…
O20140416000009 FL Part A Provider - Federally Qualified Health Center (FQHC) 6507770526 Practice locations: Tavernier, FL

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1801219258. Details of each certification follow.

Federally qualified health center certification: CCN 101147

Legal name
COMMUNITY HEALTH OF SOUTH FLORIDA INC
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Apr 16, 2014
Last certification
Apr 16, 2014
Ownership / control type
For profit – corporation
Organization structure
CorporationNon-profit
Incorporated
Oct 13, 1971 in FL
Enrollment address
91200 Overseas Hwy 17
Tavernier, FL 33070-2535

Other NPIs with the same Medicare PAC ID 17

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

View all 17

Other NPIs on the same Medicare enrollment 17

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

View all 17

National Provider Directory

National Provider Directory
Tax ID family
Community Health of South Dade Inc57 organizations share this tax ID, including this one

Organizations with this tax ID in the same state 24

This tax ID family is large, so up to 24 of its organizations in the same state are linked here.

View all 24

Ownership & related parties

All disclosed owners & managing parties 11

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

NameRoleSinceShare
Cesar Caicedo Individual Corporate DirectorBoar of Directors Jan 1, 2019
Natalie Windsor Individual Corporate DirectorBoard of Directors Jan 1, 2019
Paul Herdsman Individual Corporate DirectorBoard of Directors Jan 1, 2019
Jeremy Radziewicz Individual Corporate DirectorCfo Aug 6, 2018
W-2 Managing EmployeeCfo Aug 6, 2018
Jeffrey Coldren Individual Corporate DirectorBoard of Directors Jan 1, 2012
Andre Reid Individual Corporate DirectorBoard of Directors Jan 1, 2019
Jose Gancedo Individual Corporate DirectorBoard of Directors Jan 1, 2022
Carolyn Taylor-Pates Individual Corporate DirectorBoard of Directors Jan 1, 2012
Johnny Brown Individual Corporate DirectorBoard of Directors Jan 1, 2022
Carlo Saint Cy Individual Corporate DirectorBoard of Directors Jan 1, 2019
Anthony B Hall Individual Corporate DirectorPresident/Ceo Jan 1, 2022
W-2 Managing EmployeePresident/Ceo Jan 1, 2022

Practitioners & affiliated clinicians

Practitioners 9

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": "1390262400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1724889600000",
    "number": "1801219258",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "10300 SW 216 ST",
            "city": "MIAMI",
            "state": "FL",
            "postal_code": "331901003",
            "telephone_number": "305-253-5100",
            "fax_number": "305-252-5881"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "91200 OVERSEAS HWY",
            "address_2": "#17",
            "city": "TAVERNIER",
            "state": "FL",
            "postal_code": "330702500",
            "telephone_number": "305-253-5100"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "COMMUNITY HEALTH OF SOUTH FLORIDA, INC",
        "organizational_subpart": "NO",
        "enumeration_date": "2014-01-21",
        "last_updated": "2024-08-29",
        "certification_date": "2024-08-29",
        "status": "A",
        "authorized_official_last_name": "HALL",
        "authorized_official_first_name": "BLAKE",
        "authorized_official_title_or_position": "PRESDENT/CEO",
        "authorized_official_telephone_number": "305-252-4853",
        "authorized_official_name_prefix": "Mr."
    },
    "taxonomies": [
        {
            "code": "261QF0400X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Federally Qualified Health Center (FQHC)",
            "state": "NU",
            "license": null,
            "primary": true
        },
        {
            "code": "208D00000X",
            "taxonomy_group": "",
            "desc": "General Practice",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "251S00000X",
            "taxonomy_group": "",
            "desc": "Community/Behavioral Health",
            "state": "NU",
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "010762301",
            "state": "FL"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "010762328",
            "state": "FL"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "060303110",
            "state": "FL"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Tavernier Community Health Center",
            "code": "5",
            "type": "Other Name"
        },
        {
            "organization_name": "Tavernier Community Health Center",
            "code": "5",
            "type": "Other Name"
        }
    ]
}

Other providers in Tavernier, FL

Sources for this page

Verify at the official NPI Registry.