Provider Demographics
NPI:1164685756
Name:WUESTHOFF MEMORIAL HOSPITAL INC
Entity type:Organization
Organization Name:WUESTHOFF MEMORIAL HOSPITAL INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SVP CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:
Authorized Official - Last Name:FAYER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:321-636-2211
Mailing Address - Street 1:110 LONGWOOD AVE
Mailing Address - Street 2:MAIL STOP #24
Mailing Address - City:ROCKLEDGE
Mailing Address - State:FL
Mailing Address - Zip Code:32955-2828
Mailing Address - Country:US
Mailing Address - Phone:321-636-2211
Mailing Address - Fax:
Practice Address - Street 1:110 LONGWOOD AVE
Practice Address - Street 2:MAIL STOP #24
Practice Address - City:ROCKLEDGE
Practice Address - State:FL
Practice Address - Zip Code:32955-2828
Practice Address - Country:US
Practice Address - Phone:321-636-2211
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WUESTHOFF MEMORIAL HOSPITAL INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-07-03
Last Update Date:2008-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL4132208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)Group - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL271959200Medicaid
FL271959200Medicaid