104008
THE JEROME GOLDEN CENTER FOR BEHAVIORAL HEALTH, IN
WEST PALM BEACH, FL 33407
00320 FIPS County Code 12099 FIPCNTY
00310 FIPS State Code 12 FIPSTATE
00280 Type of Action Code 8 PR201301
00370 Affiliated Resident Program: Allopathic N PR201302
00380 Affiliated Resident Program: Dental N PR201303
00390 Affiliated Resident Program: Osteopathic N PR201304
00400 Affiliated Resident Program: Other N PR201305
01380 Services: Cardiac Catheterization Lab Code 0 PR201314
00340 Accreditation Effective Date 07/19/2011 DATE PROV0000
00350 Accreditation Expiration Date 07/18/2014 DATE PROV0005
00360 Accreditation Type Code JCAHO PROV0010
00020 Provider Category Code Hospital PROV0075
00010 Provider Category Subtype Code Psychiatric PROV0085
00030 Change of Ownership Count 1 PROV0095
00040 Change of Ownership Date DATE PROV0100
00060 Compliance: Plan of Correction N PROV0220
00750 Compliance: Life Safety Code N CMPL PROV0240
00770 Compliance: Scope of Service N CMPL PROV0280
00780 Compliance: Technical Personnel Waiver N CMPL PROV0285
00720 Compliance: 24 Hour Registered Nurse N CMPL PROV0290
00090 Cross Ref Provider Number CODE PROV0300
04850 Date of Validation Survey DATE PROV0450
00110 Eligibility Switch Yes PROV0455
00850 Fiscal Year Ending Date 0930 PROV0485
00100 Certification Date 08/13/2009 DATE PROV0500
00130 Intermediary Carrier Code 52280 PROV0605
00930 Medical School Affiliation No Affiliation PROV0645
00140 Medicare or Medicaid Vendor Number CODE PROV0655
00990 Meets 1861 Definition N CMPL PROV0670
01000 Type of Non-Participating Provider PROV0690
00630 Beds-Total 44 BEDS PROV0740
00490 Beds - Total Certified 44 BEDS PROV0755
03490 Certified Registered Nurse Anesthetists (CRNA) 0 FTES PROV0760
03530 Dietitians 0 FTES PROV0820
04460 Respiratory Therapists 0 FTES PROV0950
03670 Licensed Practical/Vocational Nurses 3 FTES PROV0955
03750 Medical Social Workers 3 FTES PROV0975
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Line Line Description TypeValue Field Name
03880 Nurse Practitioners 0 FTES PROV1015
03920 Occupational Therapists 0 FTES PROV1050
03430 Other Personnel 0 FTES PROV1075
04450 Registered Pharmacists 1 FTES PROV1100
04210 Physicians 5 FTES PROV1110
04330 Physical Therapists 0 FTES PROV1125
04470 Registered Nurses 20 FTES PROV1145
04270 Physicians (Residents) 0 FTES PROV1165
04640 Speech Pathologist or Audiologist 0 FTES PROV1220
00480 Regional Override # 1 (Number Beds) No PROV1545
03380 Regional Override # 2 (Staffing) No PROV1550
01010 Regional Override # 3 (Nurse - Bed) No PROV1555
00150 Participation Date 09/01/1970 DATE PROV1565
01080 Program Participation 1 PROV1570
00250 Telephone Number 5618449741 PROV1605
00160 Prior Change of Ownership Date DATE PROV1615
00170 Intermediary Carrier Prior Code 52280 CODE PROV1620
00950 Medicare or Medicaid Participating Provider Switch Y PROV1670
00180 Provider Number 104008 CODE PROV1680
01100 Psychiatric Unit Bed Count 0 BEDS PROV1690
01110 Psychiatric Unit Effective Date DATE PROV1695
01120 Psychiatric Unit Switch No PROV1700
01130 Psychiatric Unit Termination Code PROV1705
01140 Psychiatric Unit Termination Date DATE PROV1710
00190 Region Code Atlanta PROV1725
01150 Rehabilitation Unit Bed Count 0 BEDS PROV1730
01160 Rehabilitation Unit Effective Date DATE PROV1735
01170 Rehabilitation Unit Switch No PROV1740
01180 Rehabilitation Unit Termination Code PROV1745
01190 Rehabilitation Unit Termination Date DATE PROV1750
01200 Related Provider Number CODE PROV1755
00200 Skeleton Record Switch N PROV2045
01210 Services Provided: Acute Renal Dialysis Not Provided SVCS PROV2055
01260 Services Provided: Alcohol and/or Drug Not Provided SVCS PROV2065
01280 Services Provided: Anesthesia Not Provided SVCS PROV2070
01360 Services Provided: Burn Care Unit Not Provided SVCS PROV2090
01460 Services Provided: Chiropractic Not Provided SVCS PROV2100
01530 Services Provided: ICU Cardiac (non-surgical) Not Provided SVCS PROV2110
01580 Services Provided: Dental Not Provided SVCS PROV2120
01670 Services Provided: Dietary Provided by Staff SVCS PROV2130
01930 Services Provided: ICU Medical/Surgical Not Provided SVCS PROV2185
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Line Line Description TypeValue Field Name
01880 Services Provided: Inpatient Surgical Not Provided SVCS PROV2190
01510 Services Provided: Clinical Laboratory 2 SVCS PROV2200
02040 Services Provided: Neonatal Nursery Not Provided SVCS PROV2235
02100 Services Provided: Nuclear Medicine Not Provided SVCS PROV2245
02200 Services Provided: Obstetrics Not Provided SVCS PROV2265
02360 Services Provided: Occupational Therapy Not Provided SVCS PROV2270
01400 Services Provided: Cardiac - Thoracic Surgery Not Provided SVCS PROV2285
02240 Services Provided: Optometric Not Provided SVCS PROV2295
02260 Services Provided: Operating Rooms Not Provided SVCS PROV2300
02080 Services Provided: Organ Transplant (Not Medicare Not Provided SVCS PROV2315
02420 Services Provided: Outpatient Provided by Staff SVCS PROV2350
02480 Services Provided: Outpatient Surgery Not Provided SVCS PROV2355
02500 Services Provided: Pediatric Not Provided SVCS PROV2360
00430 Services Provided: Pharmacy Provided by Staff SVCS PROV2365
02820 Services Provided: Physical Therapy Not Provided SVCS PROV2370
02720 Services Provided: Postoperative Recovery Room Not Provided SVCS PROV2410
01230 Services Provided: Psychiatric - Adult Inpatient Provided by Staff SVCS PROV2415
01650 Services Provided: Radiology (Diagnostic) Not Provided SVCS PROV2440
03230 Services Provided: Radiology (Therapeutic) Not Provided SVCS PROV2445
02920 Services Provided: Respiratory Care Not Provided SVCS PROV2455
01630 Services Provided: Trauma Center (Designated) Not Provided SVCS PROV2475
02980 Services Provided: Social Provided by Staff SVCS PROV2485
03060 Services Provided: Speech Pathology Not Provided SVCS PROV2505
00080 SSA County Code 490 PROV2695
00220 SSA State Code 10 PROV2700
00230 State Region Code LAN PROV2710
00070 Compliance: Status Not In Compliance PROV2715
04790 Swing Bed Switch Swing Bed service not approved PROV2795
04800 Swing Bed Size Code PROV2800
00290 General Type of Control Code Voluntary Non-Profit - Private PROV2885
00410 Type of Facility Psychiatric PROV2890
00300 ZIP Code 33407 PROV2905
00210 State Abbreviation FL PROV3230
00790 Current Survey Ever Swing Bed No PROV3550
00270 Termination Date / Expiration Date 1 DATE PROV4500
00260 Termination Code 1 Active PROV4770
01310 Services Provided: Audiology Not Provided SVCS PROV6160
01440 Services Provided: Chemotherapy Not Provided SVCS PROV6170
01560 Services Provided: CT Scanner Not Provided SVCS PROV6175
01720 Services Provided: Emergency Dept(Dedicated) Not Provided SVCS PROV6180
01760 Services Provided: Extracorporeal Shock Wave Not Provided SVCS PROV6185
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Line Line Description TypeValue Field Name
01820 Services Provided: Gerontological Specialty Not Provided SVCS PROV6190
02020 Services Provided: ICU Neonatal Not Provided SVCS PROV6195
02520 Services Provided: ICU Pediatric Not Provided SVCS PROV6200
03120 Services Provided: ICU Surgical Not Provided SVCS PROV6205
02000 Services Provided: Magnetic Resonance Imaging Not Provided SVCS PROV6210
02060 Services Provided: Neurosurgical Services Not Provided SVCS PROV6215
02220 Services Provided: Ophthalmic Surgery Not Provided SVCS PROV6220
02280 Services Provided: Orthopedic Surgery Not Provided SVCS PROV6225
02540 Services Provided: PET Scan Services Not Provided SVCS PROV6230
01740 Services Provided: Psychiatric - Emergency Provided by Staff SVCS PROV6235
02740 Services Provided: Psychiatric Child/Adolescent Not Provided SVCS PROV6240
01780 Services Provided: Psychiatric - Forensic Not Provided SVCS PROV6245
01800 Services Provided: Psychiatric - Geriatric Not Provided SVCS PROV6250
02440 Services Provided: Psychiatric - Outpatient Provided by Staff SVCS PROV6255
02870 Services Provided: Reconstructive Surgery Not Provided SVCS PROV6260
02460 Services Provided: Rehabilitation Outpatient Not Provided SVCS PROV6265
01420 Services Provided: CARF Inpatient Rehabilitation C Not Provided SVCS PROV6270
01950 Services Provided: Transplant Center (Medicare Cer Not Provided SVCS PROV6275
03280 Services Provided: Urgent Care Center Services Not Provided SVCS PROV6280
03770 Medical Technologist Count 0 FTES PROV6290
03840 Nuclear Medicine Technician Count 0 FTES PROV6295
04310 Psychologist Count 0 FTES PROV6300
04440 Radiology Technician Count 0 FTES PROV6305
00840 Fax Phone Number PROV9015
04230 Physician Assistants (PA) 0 PROV9020
00330 CBSA Urban Rural Indicator U SSAMSASZ
104011
LAKE HOSP OF THE PALM BEACHES
LAKE WORTH, FL 33460
00320 FIPS County Code 12099 FIPCNTY
00310 FIPS State Code 12 FIPSTATE
00280 Type of Action Code 5 PR201301
00370 Affiliated Resident Program: Allopathic N PR201302
00380 Affiliated Resident Program: Dental N PR201303
00390 Affiliated Resident Program: Osteopathic N PR201304
00400 Affiliated Resident Program: Other N PR201305
01380 Services: Cardiac Catheterization Lab Code 0 PR201314
00340 Accreditation Effective Date 11/27/1991 DATE PROV0000
00350 Accreditation Expiration Date 11/27/1994 DATE PROV0005
00360 Accreditation Type Code JCAHO PROV0010
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Line Line Description TypeValue Field Name
00020 Provider Category Code Hospital PROV0075
00010 Provider Category Subtype Code Psychiatric PROV0085
00030 Change of Ownership Count 0 PROV0095
00040 Change of Ownership Date DATE PROV0100
00060 Compliance: Plan of Correction N PROV0220
00750 Compliance: Life Safety Code N CMPL PROV0240
00770 Compliance: Scope of Service N CMPL PROV0280
00780 Compliance: Technical Personnel Waiver N CMPL PROV0285
00720 Compliance: 24 Hour Registered Nurse N CMPL PROV0290
00090 Cross Ref Provider Number CODE PROV0300
04850 Date of Validation Survey 01/07/1992 DATE PROV0450
00110 Eligibility Switch No PROV0455
00850 Fiscal Year Ending Date 0531 PROV0485
00100 Certification Date 01/07/1992 DATE PROV0500
00130 Intermediary Carrier Code 00090 PROV0605
00930 Medical School Affiliation No Affiliation PROV0645
00140 Medicare or Medicaid Vendor Number CODE PROV0655
00990 Meets 1861 Definition N CMPL PROV0670
01000 Type of Non-Participating Provider PROV0690
00630 Beds-Total 98 BEDS PROV0740
00490 Beds - Total Certified 98 BEDS PROV0755
03490 Certified Registered Nurse Anesthetists (CRNA) 0 FTES PROV0760
03530 Dietitians 1 FTES PROV0820
04460 Respiratory Therapists 0 FTES PROV0950
03670 Licensed Practical/Vocational Nurses 2 FTES PROV0955
03750 Medical Social Workers 5 FTES PROV0975
03880 Nurse Practitioners 0 FTES PROV1015
03920 Occupational Therapists 1 FTES PROV1050
03430 Other Personnel 19 FTES PROV1075
04450 Registered Pharmacists 0 FTES PROV1100
04210 Physicians 0 FTES PROV1110
04330 Physical Therapists 0 FTES PROV1125
04470 Registered Nurses 19 FTES PROV1145
04270 Physicians (Residents) 0 FTES PROV1165
04640 Speech Pathologist or Audiologist 0 FTES PROV1220
00480 Regional Override # 1 (Number Beds) No PROV1545
03380 Regional Override # 2 (Staffing) Yes PROV1550
01010 Regional Override # 3 (Nurse - Bed) No PROV1555
00150 Participation Date 10/01/1973 DATE PROV1565
01080 Program Participation 1 PROV1570
00250 Telephone Number 4075887341 PROV1605
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Line Line Description TypeValue Field Name
00160 Prior Change of Ownership Date DATE PROV1615
00170 Intermediary Carrier Prior Code CODE PROV1620
00950 Medicare or Medicaid Participating Provider Switch Y PROV1670
00180 Provider Number 104011 CODE PROV1680
01100 Psychiatric Unit Bed Count 0 BEDS PROV1690
01110 Psychiatric Unit Effective Date DATE PROV1695
01120 Psychiatric Unit Switch No PROV1700
01130 Psychiatric Unit Termination Code PROV1705
01140 Psychiatric Unit Termination Date DATE PROV1710
00190 Region Code Atlanta PROV1725
01150 Rehabilitation Unit Bed Count 0 BEDS PROV1730
01160 Rehabilitation Unit Effective Date DATE PROV1735
01170 Rehabilitation Unit Switch No PROV1740
01180 Rehabilitation Unit Termination Code PROV1745
01190 Rehabilitation Unit Termination Date DATE PROV1750
01200 Related Provider Number CODE PROV1755
00200 Skeleton Record Switch N PROV2045
01210 Services Provided: Acute Renal Dialysis Not Provided SVCS PROV2055
01260 Services Provided: Alcohol and/or Drug Not Provided SVCS PROV2065
01280 Services Provided: Anesthesia Not Provided SVCS PROV2070
01360 Services Provided: Burn Care Unit Not Provided SVCS PROV2090
01460 Services Provided: Chiropractic Not Provided SVCS PROV2100
01530 Services Provided: ICU Cardiac (non-surgical) Not Provided SVCS PROV2110
01580 Services Provided: Dental Not Provided SVCS PROV2120
01670 Services Provided: Dietary Provided by Staff SVCS PROV2130
01930 Services Provided: ICU Medical/Surgical Not Provided SVCS PROV2185
01880 Services Provided: Inpatient Surgical Not Provided SVCS PROV2190
01510 Services Provided: Clinical Laboratory 1 SVCS PROV2200
02040 Services Provided: Neonatal Nursery Not Provided SVCS PROV2235
02100 Services Provided: Nuclear Medicine Not Provided SVCS PROV2245
02200 Services Provided: Obstetrics Not Provided SVCS PROV2265
02360 Services Provided: Occupational Therapy Provided by Staff and Arrangement
SVCS PROV2270
01400 Services Provided: Cardiac - Thoracic Surgery Not Provided SVCS PROV2285
02240 Services Provided: Optometric Not Provided SVCS PROV2295
02260 Services Provided: Operating Rooms Not Provided SVCS PROV2300
02080 Services Provided: Organ Transplant (Not Medicare Not Provided SVCS PROV2315
02420 Services Provided: Outpatient Not Provided SVCS PROV2350
02480 Services Provided: Outpatient Surgery Not Provided SVCS PROV2355
02500 Services Provided: Pediatric Not Provided SVCS PROV2360
00430 Services Provided: Pharmacy Provided under Arrangement SVCS PROV2365
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Line Line Description TypeValue Field Name
02820 Services Provided: Physical Therapy Provided under Arrangement SVCS PROV2370
02720 Services Provided: Postoperative Recovery Room Not Provided SVCS PROV2410
01230 Services Provided: Psychiatric - Adult Inpatient Provided by Staff SVCS PROV2415
01650 Services Provided: Radiology (Diagnostic) Provided by Staff and Arrangement
SVCS PROV2440
03230 Services Provided: Radiology (Therapeutic) Not Provided SVCS PROV2445
02920 Services Provided: Respiratory Care Not Provided SVCS PROV2455
01630 Services Provided: Trauma Center (Designated) Not Provided SVCS PROV2475
02980 Services Provided: Social Provided by Staff SVCS PROV2485
03060 Services Provided: Speech Pathology Provided under Arrangement SVCS PROV2505
00080 SSA County Code 490 PROV2695
00220 SSA State Code 10 PROV2700
00230 State Region Code LAN PROV2710
00070 Compliance: Status In Compliance PROV2715
04790 Swing Bed Switch Swing Bed service not approved PROV2795
04800 Swing Bed Size Code PROV2800
00290 General Type of Control Code Voluntary Non-Profit - Private PROV2885
00410 Type of Facility Psychiatric PROV2890
00300 ZIP Code 33460 PROV2905
00210 State Abbreviation FL PROV3230
00790 Current Survey Ever Swing Bed No PROV3550
00270 Termination Date / Expiration Date 1 05/31/1992 DATE PROV4500
00260 Termination Code 1 Voluntary - Merge,Close PROV4770
01310 Services Provided: Audiology Not Provided SVCS PROV6160
01440 Services Provided: Chemotherapy Not Provided SVCS PROV6170
01560 Services Provided: CT Scanner Not Provided SVCS PROV6175
01720 Services Provided: Emergency Dept(Dedicated) Provided under Arrangement SVCS PROV6180
01760 Services Provided: Extracorporeal Shock Wave Not Provided SVCS PROV6185
01820 Services Provided: Gerontological Specialty Not Provided SVCS PROV6190
02020 Services Provided: ICU Neonatal Not Provided SVCS PROV6195
02520 Services Provided: ICU Pediatric Not Provided SVCS PROV6200
03120 Services Provided: ICU Surgical Not Provided SVCS PROV6205
02000 Services Provided: Magnetic Resonance Imaging Not Provided SVCS PROV6210
02060 Services Provided: Neurosurgical Services Not Provided SVCS PROV6215
02220 Services Provided: Ophthalmic Surgery Not Provided SVCS PROV6220
02280 Services Provided: Orthopedic Surgery Not Provided SVCS PROV6225
02540 Services Provided: PET Scan Services Not Provided SVCS PROV6230
01740 Services Provided: Psychiatric - Emergency Not Provided SVCS PROV6235
02740 Services Provided: Psychiatric Child/Adolescent Not Provided SVCS PROV6240
01780 Services Provided: Psychiatric - Forensic Not Provided SVCS PROV6245
01800 Services Provided: Psychiatric - Geriatric Not Provided SVCS PROV6250
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Line Line Description TypeValue Field Name
02440 Services Provided: Psychiatric - Outpatient Not Provided SVCS PROV6255
02870 Services Provided: Reconstructive Surgery Not Provided SVCS PROV6260
02460 Services Provided: Rehabilitation Outpatient Not Provided SVCS PROV6265
01420 Services Provided: CARF Inpatient Rehabilitation C Not Provided SVCS PROV6270
01950 Services Provided: Transplant Center (Medicare Cer Not Provided SVCS PROV6275
03280 Services Provided: Urgent Care Center Services Not Provided SVCS PROV6280
03770 Medical Technologist Count 0 FTES PROV6290
03840 Nuclear Medicine Technician Count 0 FTES PROV6295
04310 Psychologist Count 0 FTES PROV6300
04440 Radiology Technician Count 0 FTES PROV6305
00840 Fax Phone Number PROV9015
04230 Physician Assistants (PA) 0 PROV9020
00330 CBSA Urban Rural Indicator U SSAMSASZ
103030
PINECREST REHABILITATION HOSPITAL
DELRAY BEACH, FL 33484
00320 FIPS County Code 12099 FIPCNTY
00310 FIPS State Code 12 FIPSTATE
00280 Type of Action Code 2 PR201301
00370 Affiliated Resident Program: Allopathic N PR201302
00380 Affiliated Resident Program: Dental N PR201303
00390 Affiliated Resident Program: Osteopathic N PR201304
00400 Affiliated Resident Program: Other N PR201305
01380 Services: Cardiac Catheterization Lab Code 0 PR201314
00340 Accreditation Effective Date 09/08/2001 DATE PROV0000
00350 Accreditation Expiration Date 09/08/2004 DATE PROV0005
00360 Accreditation Type Code JCAHO PROV0010
00020 Provider Category Code Hospital PROV0075
00010 Provider Category Subtype Code Rehabilitation PROV0085
00030 Change of Ownership Count 0 PROV0095
00040 Change of Ownership Date DATE PROV0100
00060 Compliance: Plan of Correction N PROV0220
00750 Compliance: Life Safety Code N CMPL PROV0240
00770 Compliance: Scope of Service N CMPL PROV0280
00780 Compliance: Technical Personnel Waiver N CMPL PROV0285
00720 Compliance: 24 Hour Registered Nurse N CMPL PROV0290
00090 Cross Ref Provider Number CODE PROV0300
04850 Date of Validation Survey DATE PROV0450
00110 Eligibility Switch Yes PROV0455
00850 Fiscal Year Ending Date 0531 PROV0485
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Line Line Description TypeValue Field Name
00100 Certification Date 10/22/1992 DATE PROV0500
00130 Intermediary Carrier Code 52280 PROV0605
00930 Medical School Affiliation No Affiliation PROV0645
00140 Medicare or Medicaid Vendor Number CODE PROV0655
00990 Meets 1861 Definition N CMPL PROV0670
01000 Type of Non-Participating Provider PROV0690
00630 Beds-Total 90 BEDS PROV0740
00490 Beds - Total Certified 90 BEDS PROV0755
03490 Certified Registered Nurse Anesthetists (CRNA) 0 FTES PROV0760
03530 Dietitians 1 FTES PROV0820
04460 Respiratory Therapists 0 FTES PROV0950
03670 Licensed Practical/Vocational Nurses 40 FTES PROV0955
03750 Medical Social Workers 8 FTES PROV0975
03880 Nurse Practitioners 0 FTES PROV1015
03920 Occupational Therapists 19 FTES PROV1050
03430 Other Personnel 15 FTES PROV1075
04450 Registered Pharmacists 0 FTES PROV1100
04210 Physicians 0 FTES PROV1110
04330 Physical Therapists 26 FTES PROV1125
04470 Registered Nurses 28 FTES PROV1145
04270 Physicians (Residents) 0 FTES PROV1165
04640 Speech Pathologist or Audiologist 12 FTES PROV1220
00480 Regional Override # 1 (Number Beds) No PROV1545
03380 Regional Override # 2 (Staffing) No PROV1550
01010 Regional Override # 3 (Nurse - Bed) No PROV1555
00150 Participation Date 04/22/1986 DATE PROV1565
01080 Program Participation 3 PROV1570
00250 Telephone Number 5614950400 PROV1605
00160 Prior Change of Ownership Date DATE PROV1615
00170 Intermediary Carrier Prior Code 51390 CODE PROV1620
00950 Medicare or Medicaid Participating Provider Switch Y PROV1670
00180 Provider Number 103030 CODE PROV1680
01100 Psychiatric Unit Bed Count 0 BEDS PROV1690
01110 Psychiatric Unit Effective Date DATE PROV1695
01120 Psychiatric Unit Switch No PROV1700
01130 Psychiatric Unit Termination Code PROV1705
01140 Psychiatric Unit Termination Date DATE PROV1710
00190 Region Code Atlanta PROV1725
01150 Rehabilitation Unit Bed Count 0 BEDS PROV1730
01160 Rehabilitation Unit Effective Date DATE PROV1735
01170 Rehabilitation Unit Switch No PROV1740
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Line Line Description TypeValue Field Name
01180 Rehabilitation Unit Termination Code PROV1745
01190 Rehabilitation Unit Termination Date DATE PROV1750
01200 Related Provider Number CODE PROV1755
00200 Skeleton Record Switch N PROV2045
01210 Services Provided: Acute Renal Dialysis Not Provided SVCS PROV2055
01260 Services Provided: Alcohol and/or Drug Not Provided SVCS PROV2065
01280 Services Provided: Anesthesia Provided under Arrangement SVCS PROV2070
01360 Services Provided: Burn Care Unit Not Provided SVCS PROV2090
01460 Services Provided: Chiropractic Not Provided SVCS PROV2100
01530 Services Provided: ICU Cardiac (non-surgical) Provided under Arrangement SVCS PROV2110
01580 Services Provided: Dental Not Provided SVCS PROV2120
01670 Services Provided: Dietary Provided by Staff SVCS PROV2130
01930 Services Provided: ICU Medical/Surgical Provided under Arrangement SVCS PROV2185
01880 Services Provided: Inpatient Surgical Provided under Arrangement SVCS PROV2190
01510 Services Provided: Clinical Laboratory 2 SVCS PROV2200
02040 Services Provided: Neonatal Nursery Not Provided SVCS PROV2235
02100 Services Provided: Nuclear Medicine Provided under Arrangement SVCS PROV2245
02200 Services Provided: Obstetrics Provided under Arrangement SVCS PROV2265
02360 Services Provided: Occupational Therapy Provided by Staff SVCS PROV2270
01400 Services Provided: Cardiac - Thoracic Surgery Not Provided SVCS PROV2285
02240 Services Provided: Optometric Not Provided SVCS PROV2295
02260 Services Provided: Operating Rooms Provided under Arrangement SVCS PROV2300
02080 Services Provided: Organ Transplant (Not Medicare Not Provided SVCS PROV2315
02420 Services Provided: Outpatient Provided by Staff SVCS PROV2350
02480 Services Provided: Outpatient Surgery Provided under Arrangement SVCS PROV2355
02500 Services Provided: Pediatric Not Provided SVCS PROV2360
00430 Services Provided: Pharmacy Provided under Arrangement SVCS PROV2365
02820 Services Provided: Physical Therapy Provided by Staff SVCS PROV2370
02720 Services Provided: Postoperative Recovery Room Provided under Arrangement SVCS PROV2410
01230 Services Provided: Psychiatric - Adult Inpatient Not Provided SVCS PROV2415
01650 Services Provided: Radiology (Diagnostic) Provided under Arrangement SVCS PROV2440
03230 Services Provided: Radiology (Therapeutic) Provided under Arrangement SVCS PROV2445
02920 Services Provided: Respiratory Care Provided under Arrangement SVCS PROV2455
01630 Services Provided: Trauma Center (Designated) Not Provided SVCS PROV2475
02980 Services Provided: Social Provided by Staff SVCS PROV2485
03060 Services Provided: Speech Pathology Provided by Staff SVCS PROV2505
00080 SSA County Code 490 PROV2695
00220 SSA State Code 10 PROV2700
00230 State Region Code LAN PROV2710
00070 Compliance: Status In Compliance PROV2715
04790 Swing Bed Switch Swing Bed service not approved PROV2795
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Line Line Description TypeValue Field Name
04800 Swing Bed Size Code PROV2800
00290 General Type of Control Code Proprietary PROV2885
00410 Type of Facility Rehabilitation PROV2890
00300 ZIP Code 33484 PROV2905
00210 State Abbreviation FL PROV3230
00790 Current Survey Ever Swing Bed No PROV3550
00270 Termination Date / Expiration Date 1 06/01/2007 DATE PROV4500
00260 Termination Code 1 Voluntary - Merge,Close PROV4770
01310 Services Provided: Audiology Not Provided SVCS PROV6160
01440 Services Provided: Chemotherapy Not Provided SVCS PROV6170
01560 Services Provided: CT Scanner Not Provided SVCS PROV6175
01720 Services Provided: Emergency Dept(Dedicated) Provided under Arrangement SVCS PROV6180
01760 Services Provided: Extracorporeal Shock Wave Not Provided SVCS PROV6185
01820 Services Provided: Gerontological Specialty Not Provided SVCS PROV6190
02020 Services Provided: ICU Neonatal Not Provided SVCS PROV6195
02520 Services Provided: ICU Pediatric Not Provided SVCS PROV6200
03120 Services Provided: ICU Surgical Not Provided SVCS PROV6205
02000 Services Provided: Magnetic Resonance Imaging Not Provided SVCS PROV6210
02060 Services Provided: Neurosurgical Services Not Provided SVCS PROV6215
02220 Services Provided: Ophthalmic Surgery Not Provided SVCS PROV6220
02280 Services Provided: Orthopedic Surgery Not Provided SVCS PROV6225
02540 Services Provided: PET Scan Services Not Provided SVCS PROV6230
01740 Services Provided: Psychiatric - Emergency Not Provided SVCS PROV6235
02740 Services Provided: Psychiatric Child/Adolescent Not Provided SVCS PROV6240
01780 Services Provided: Psychiatric - Forensic Not Provided SVCS PROV6245
01800 Services Provided: Psychiatric - Geriatric Not Provided SVCS PROV6250
02440 Services Provided: Psychiatric - Outpatient Not Provided SVCS PROV6255
02870 Services Provided: Reconstructive Surgery Not Provided SVCS PROV6260
02460 Services Provided: Rehabilitation Outpatient Not Provided SVCS PROV6265
01420 Services Provided: CARF Inpatient Rehabilitation C Not Provided SVCS PROV6270
01950 Services Provided: Transplant Center (Medicare Cer Not Provided SVCS PROV6275
03280 Services Provided: Urgent Care Center Services Not Provided SVCS PROV6280
03770 Medical Technologist Count 0 FTES PROV6290
03840 Nuclear Medicine Technician Count 0 FTES PROV6295
04310 Psychologist Count 0 FTES PROV6300
04440 Radiology Technician Count 0 FTES PROV6305
00840 Fax Phone Number PROV9015
04230 Physician Assistants (PA) 0 PROV9020
00330 CBSA Urban Rural Indicator U SSAMSASZ
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Line Line Description TypeValue Field Name
102025
KINDRED HOSPITAL THE PALM BEACHES
RIVIERA BEACH, FL 33418
00320 FIPS County Code 12099 FIPCNTY
00310 FIPS State Code 12 FIPSTATE
00280 Type of Action Code 8 PR201301
00370 Affiliated Resident Program: Allopathic N PR201302
00380 Affiliated Resident Program: Dental N PR201303
00390 Affiliated Resident Program: Osteopathic N PR201304
00400 Affiliated Resident Program: Other N PR201305
01380 Services: Cardiac Catheterization Lab Code 0 PR201314
00340 Accreditation Effective Date 11/19/2009 DATE PROV0000
00350 Accreditation Expiration Date 06/15/2015 DATE PROV0005
00360 Accreditation Type Code JCAHO PROV0010
00020 Provider Category Code Hospital PROV0075
00010 Provider Category Subtype Code Long Term PROV0085
00030 Change of Ownership Count 1 PROV0095
00040 Change of Ownership Date DATE PROV0100
00060 Compliance: Plan of Correction N PROV0220
00750 Compliance: Life Safety Code N CMPL PROV0240
00770 Compliance: Scope of Service N CMPL PROV0280
00780 Compliance: Technical Personnel Waiver N CMPL PROV0285
00720 Compliance: 24 Hour Registered Nurse N CMPL PROV0290
00090 Cross Ref Provider Number CODE PROV0300
04850 Date of Validation Survey DATE PROV0450
00110 Eligibility Switch Yes PROV0455
00850 Fiscal Year Ending Date 0531 PROV0485
00100 Certification Date 07/13/2011 DATE PROV0500
00130 Intermediary Carrier Code 00090 PROV0605
00930 Medical School Affiliation No Affiliation PROV0645
00140 Medicare or Medicaid Vendor Number CODE PROV0655
00990 Meets 1861 Definition N CMPL PROV0670
01000 Type of Non-Participating Provider PROV0690
00630 Beds-Total 70 BEDS PROV0740
00490 Beds - Total Certified 70 BEDS PROV0755
03490 Certified Registered Nurse Anesthetists (CRNA) 23 FTES PROV0760
03530 Dietitians 2 FTES PROV0820
04460 Respiratory Therapists 14 FTES PROV0950
03670 Licensed Practical/Vocational Nurses 3 FTES PROV0955
03750 Medical Social Workers 3 FTES PROV0975
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Line Line Description TypeValue Field Name
03880 Nurse Practitioners 0 FTES PROV1015
03920 Occupational Therapists 2 FTES PROV1050
03430 Other Personnel 36 FTES PROV1075
04450 Registered Pharmacists 4 FTES PROV1100
04210 Physicians 0 FTES PROV1110
04330 Physical Therapists 2 FTES PROV1125
04470 Registered Nurses 44 FTES PROV1145
04270 Physicians (Residents) 0 FTES PROV1165
04640 Speech Pathologist or Audiologist 2 FTES PROV1220
00480 Regional Override # 1 (Number Beds) Yes PROV1545
03380 Regional Override # 2 (Staffing) Yes PROV1550
01010 Regional Override # 3 (Nurse - Bed) No PROV1555
00150 Participation Date 06/01/2009 DATE PROV1565
01080 Program Participation 3 PROV1570
00250 Telephone Number 5618400754 PROV1605
00160 Prior Change of Ownership Date DATE PROV1615
00170 Intermediary Carrier Prior Code 00090 CODE PROV1620
00950 Medicare or Medicaid Participating Provider Switch Y PROV1670
00180 Provider Number 102025 CODE PROV1680
01100 Psychiatric Unit Bed Count 0 BEDS PROV1690
01110 Psychiatric Unit Effective Date DATE PROV1695
01120 Psychiatric Unit Switch No PROV1700
01130 Psychiatric Unit Termination Code PROV1705
01140 Psychiatric Unit Termination Date DATE PROV1710
00190 Region Code Atlanta PROV1725
01150 Rehabilitation Unit Bed Count 0 BEDS PROV1730
01160 Rehabilitation Unit Effective Date DATE PROV1735
01170 Rehabilitation Unit Switch No PROV1740
01180 Rehabilitation Unit Termination Code PROV1745
01190 Rehabilitation Unit Termination Date DATE PROV1750
01200 Related Provider Number CODE PROV1755
00200 Skeleton Record Switch N PROV2045
01210 Services Provided: Acute Renal Dialysis Provided by Staff and Arrangement
SVCS PROV2055
01260 Services Provided: Alcohol and/or Drug Not Provided SVCS PROV2065
01280 Services Provided: Anesthesia Provided by Staff and Arrangement
SVCS PROV2070
01360 Services Provided: Burn Care Unit Not Provided SVCS PROV2090
01460 Services Provided: Chiropractic Not Provided SVCS PROV2100
01530 Services Provided: ICU Cardiac (non-surgical) Provided by Staff and Arrangement
SVCS PROV2110
01580 Services Provided: Dental Not Provided SVCS PROV2120
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Line Line Description TypeValue Field Name
01670 Services Provided: Dietary Provided by Staff and Arrangement
SVCS PROV2130
01930 Services Provided: ICU Medical/Surgical Provided by Staff and Arrangement
SVCS PROV2185
01880 Services Provided: Inpatient Surgical Provided by Staff and Arrangement
SVCS PROV2190
01510 Services Provided: Clinical Laboratory 3 SVCS PROV2200
02040 Services Provided: Neonatal Nursery Not Provided SVCS PROV2235
02100 Services Provided: Nuclear Medicine Not Provided SVCS PROV2245
02200 Services Provided: Obstetrics Not Provided SVCS PROV2265
02360 Services Provided: Occupational Therapy Provided by Staff and Arrangement
SVCS PROV2270
01400 Services Provided: Cardiac - Thoracic Surgery Not Provided SVCS PROV2285
02240 Services Provided: Optometric Not Provided SVCS PROV2295
02260 Services Provided: Operating Rooms Provided by Staff and Arrangement
SVCS PROV2300
02080 Services Provided: Organ Transplant (Not Medicare Not Provided SVCS PROV2315
02420 Services Provided: Outpatient Not Provided SVCS PROV2350
02480 Services Provided: Outpatient Surgery Not Provided SVCS PROV2355
02500 Services Provided: Pediatric Not Provided SVCS PROV2360
00430 Services Provided: Pharmacy Provided by Staff and Arrangement
SVCS PROV2365
02820 Services Provided: Physical Therapy Not Provided SVCS PROV2370
02720 Services Provided: Postoperative Recovery Room Provided by Staff and Arrangement
SVCS PROV2410
01230 Services Provided: Psychiatric - Adult Inpatient Not Provided SVCS PROV2415
01650 Services Provided: Radiology (Diagnostic) Provided by Staff and Arrangement
SVCS PROV2440
03230 Services Provided: Radiology (Therapeutic) Not Provided SVCS PROV2445
02920 Services Provided: Respiratory Care Provided by Staff and Arrangement
SVCS PROV2455
01630 Services Provided: Trauma Center (Designated) Not Provided SVCS PROV2475
02980 Services Provided: Social Provided by Staff and Arrangement
SVCS PROV2485
03060 Services Provided: Speech Pathology Provided by Staff and Arrangement
SVCS PROV2505
00080 SSA County Code 490 PROV2695
00220 SSA State Code 10 PROV2700
00230 State Region Code LAN PROV2710
00070 Compliance: Status In Compliance PROV2715
04790 Swing Bed Switch Swing Bed service not approved PROV2795
04800 Swing Bed Size Code PROV2800
00290 General Type of Control Code Proprietary PROV2885
00410 Type of Facility Long - Term PROV2890
00300 ZIP Code 33418 PROV2905
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Line Line Description TypeValue Field Name
00210 State Abbreviation FL PROV3230
00790 Current Survey Ever Swing Bed No PROV3550
00270 Termination Date / Expiration Date 1 DATE PROV4500
00260 Termination Code 1 Active PROV4770
01310 Services Provided: Audiology Not Provided SVCS PROV6160
01440 Services Provided: Chemotherapy Not Provided SVCS PROV6170
01560 Services Provided: CT Scanner Provided by Staff and Arrangement
SVCS PROV6175
01720 Services Provided: Emergency Dept(Dedicated) Not Provided SVCS PROV6180
01760 Services Provided: Extracorporeal Shock Wave Not Provided SVCS PROV6185
01820 Services Provided: Gerontological Specialty Not Provided SVCS PROV6190
02020 Services Provided: ICU Neonatal Not Provided SVCS PROV6195
02520 Services Provided: ICU Pediatric Not Provided SVCS PROV6200
03120 Services Provided: ICU Surgical Not Provided SVCS PROV6205
02000 Services Provided: Magnetic Resonance Imaging Not Provided SVCS PROV6210
02060 Services Provided: Neurosurgical Services Not Provided SVCS PROV6215
02220 Services Provided: Ophthalmic Surgery Not Provided SVCS PROV6220
02280 Services Provided: Orthopedic Surgery Not Provided SVCS PROV6225
02540 Services Provided: PET Scan Services Not Provided SVCS PROV6230
01740 Services Provided: Psychiatric - Emergency Not Provided SVCS PROV6235
02740 Services Provided: Psychiatric Child/Adolescent Not Provided SVCS PROV6240
01780 Services Provided: Psychiatric - Forensic Not Provided SVCS PROV6245
01800 Services Provided: Psychiatric - Geriatric Not Provided SVCS PROV6250
02440 Services Provided: Psychiatric - Outpatient Not Provided SVCS PROV6255
02870 Services Provided: Reconstructive Surgery Not Provided SVCS PROV6260
02460 Services Provided: Rehabilitation Outpatient Not Provided SVCS PROV6265
01420 Services Provided: CARF Inpatient Rehabilitation C Provided by Staff and Arrangement
SVCS PROV6270
01950 Services Provided: Transplant Center (Medicare Cer Not Provided SVCS PROV6275
03280 Services Provided: Urgent Care Center Services Not Provided SVCS PROV6280
03770 Medical Technologist Count 4 FTES PROV6290
03840 Nuclear Medicine Technician Count 0 FTES PROV6295
04310 Psychologist Count 0 FTES PROV6300
04440 Radiology Technician Count 2 FTES PROV6305
00840 Fax Phone Number 5618420271 PROV9015
04230 Physician Assistants (PA) 0 PROV9020
00330 CBSA Urban Rural Indicator U SSAMSASZ
102023
SELECT SPECIALTY HOSPITAL-PALM BEACH
LAKE WORTH, FL 33461
00320 FIPS County Code 12099 FIPCNTY
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Line Line Description TypeValue Field Name
00310 FIPS State Code 12 FIPSTATE
00280 Type of Action Code 2 PR201301
00370 Affiliated Resident Program: Allopathic N PR201302
00380 Affiliated Resident Program: Dental N PR201303
00390 Affiliated Resident Program: Osteopathic N PR201304
00400 Affiliated Resident Program: Other N PR201305
01380 Services: Cardiac Catheterization Lab Code 0 PR201314
00340 Accreditation Effective Date 10/17/2009 DATE PROV0000
00350 Accreditation Expiration Date 10/12/2015 DATE PROV0005
00360 Accreditation Type Code JCAHO PROV0010
00020 Provider Category Code Hospital PROV0075
00010 Provider Category Subtype Code Long Term PROV0085
00030 Change of Ownership Count 0 PROV0095
00040 Change of Ownership Date DATE PROV0100
00060 Compliance: Plan of Correction N PROV0220
00750 Compliance: Life Safety Code N CMPL PROV0240
00770 Compliance: Scope of Service N CMPL PROV0280
00780 Compliance: Technical Personnel Waiver N CMPL PROV0285
00720 Compliance: 24 Hour Registered Nurse N CMPL PROV0290
00090 Cross Ref Provider Number 100309 CODE PROV0300
04850 Date of Validation Survey DATE PROV0450
00110 Eligibility Switch Yes PROV0455
00850 Fiscal Year Ending Date 1130 PROV0485
00100 Certification Date 05/07/2008 DATE PROV0500
00130 Intermediary Carrier Code 00090 PROV0605
00930 Medical School Affiliation No Affiliation PROV0645
00140 Medicare or Medicaid Vendor Number CODE PROV0655
00990 Meets 1861 Definition N CMPL PROV0670
01000 Type of Non-Participating Provider PROV0690
00630 Beds-Total 60 BEDS PROV0740
00490 Beds - Total Certified 60 BEDS PROV0755
03490 Certified Registered Nurse Anesthetists (CRNA) 0 FTES PROV0760
03530 Dietitians 0 FTES PROV0820
04460 Respiratory Therapists 5 FTES PROV0950
03670 Licensed Practical/Vocational Nurses 0 FTES PROV0955
03750 Medical Social Workers 0 FTES PROV0975
03880 Nurse Practitioners 0 FTES PROV1015
03920 Occupational Therapists 0 FTES PROV1050
03430 Other Personnel 28 FTES PROV1075
04450 Registered Pharmacists 2 FTES PROV1100
04210 Physicians 0 FTES PROV1110
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Line Line Description TypeValue Field Name
04330 Physical Therapists 1 FTES PROV1125
04470 Registered Nurses 13 FTES PROV1145
04270 Physicians (Residents) 0 FTES PROV1165
04640 Speech Pathologist or Audiologist 0 FTES PROV1220
00480 Regional Override # 1 (Number Beds) No PROV1545
03380 Regional Override # 2 (Staffing) No PROV1550
01010 Regional Override # 3 (Nurse - Bed) No PROV1555
00150 Participation Date 12/01/2008 DATE PROV1565
01080 Program Participation 3 PROV1570
00250 Telephone Number 5613577200 PROV1605
00160 Prior Change of Ownership Date DATE PROV1615
00170 Intermediary Carrier Prior Code 00090 CODE PROV1620
00950 Medicare or Medicaid Participating Provider Switch Y PROV1670
00180 Provider Number 102023 CODE PROV1680
01100 Psychiatric Unit Bed Count 0 BEDS PROV1690
01110 Psychiatric Unit Effective Date DATE PROV1695
01120 Psychiatric Unit Switch No PROV1700
01130 Psychiatric Unit Termination Code PROV1705
01140 Psychiatric Unit Termination Date DATE PROV1710
00190 Region Code Atlanta PROV1725
01150 Rehabilitation Unit Bed Count 0 BEDS PROV1730
01160 Rehabilitation Unit Effective Date DATE PROV1735
01170 Rehabilitation Unit Switch No PROV1740
01180 Rehabilitation Unit Termination Code PROV1745
01190 Rehabilitation Unit Termination Date DATE PROV1750
01200 Related Provider Number CODE PROV1755
00200 Skeleton Record Switch N PROV2045
01210 Services Provided: Acute Renal Dialysis Not Provided SVCS PROV2055
01260 Services Provided: Alcohol and/or Drug Not Provided SVCS PROV2065
01280 Services Provided: Anesthesia Not Provided SVCS PROV2070
01360 Services Provided: Burn Care Unit Not Provided SVCS PROV2090
01460 Services Provided: Chiropractic Not Provided SVCS PROV2100
01530 Services Provided: ICU Cardiac (non-surgical) Not Provided SVCS PROV2110
01580 Services Provided: Dental Not Provided SVCS PROV2120
01670 Services Provided: Dietary Not Provided SVCS PROV2130
01930 Services Provided: ICU Medical/Surgical Provided by Staff SVCS PROV2185
01880 Services Provided: Inpatient Surgical Provided by Staff SVCS PROV2190
01510 Services Provided: Clinical Laboratory 3 SVCS PROV2200
02040 Services Provided: Neonatal Nursery Not Provided SVCS PROV2235
02100 Services Provided: Nuclear Medicine Not Provided SVCS PROV2245
02200 Services Provided: Obstetrics Not Provided SVCS PROV2265
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Line Line Description TypeValue Field Name
02360 Services Provided: Occupational Therapy Provided by Staff and Arrangement
SVCS PROV2270
01400 Services Provided: Cardiac - Thoracic Surgery Not Provided SVCS PROV2285
02240 Services Provided: Optometric Not Provided SVCS PROV2295
02260 Services Provided: Operating Rooms Not Provided SVCS PROV2300
02080 Services Provided: Organ Transplant (Not Medicare Not Provided SVCS PROV2315
02420 Services Provided: Outpatient Not Provided SVCS PROV2350
02480 Services Provided: Outpatient Surgery Not Provided SVCS PROV2355
02500 Services Provided: Pediatric Not Provided SVCS PROV2360
00430 Services Provided: Pharmacy Provided by Staff and Arrangement
SVCS PROV2365
02820 Services Provided: Physical Therapy Provided by Staff and Arrangement
SVCS PROV2370
02720 Services Provided: Postoperative Recovery Room Not Provided SVCS PROV2410
01230 Services Provided: Psychiatric - Adult Inpatient Not Provided SVCS PROV2415
01650 Services Provided: Radiology (Diagnostic) Provided by Staff and Arrangement
SVCS PROV2440
03230 Services Provided: Radiology (Therapeutic) Not Provided SVCS PROV2445
02920 Services Provided: Respiratory Care Provided by Staff SVCS PROV2455
01630 Services Provided: Trauma Center (Designated) Not Provided SVCS PROV2475
02980 Services Provided: Social Not Provided SVCS PROV2485
03060 Services Provided: Speech Pathology Provided by Staff and Arrangement
SVCS PROV2505
00080 SSA County Code 490 PROV2695
00220 SSA State Code 10 PROV2700
00230 State Region Code LAU PROV2710
00070 Compliance: Status In Compliance PROV2715
04790 Swing Bed Switch Swing Bed service not approved PROV2795
04800 Swing Bed Size Code PROV2800
00290 General Type of Control Code Proprietary PROV2885
00410 Type of Facility Long - Term PROV2890
00300 ZIP Code 33461 PROV2905
00210 State Abbreviation FL PROV3230
00790 Current Survey Ever Swing Bed No PROV3550
00270 Termination Date / Expiration Date 1 DATE PROV4500
00260 Termination Code 1 Active PROV4770
01310 Services Provided: Audiology Not Provided SVCS PROV6160
01440 Services Provided: Chemotherapy Not Provided SVCS PROV6170
01560 Services Provided: CT Scanner Provided by Staff SVCS PROV6175
01720 Services Provided: Emergency Dept(Dedicated) Not Provided SVCS PROV6180
01760 Services Provided: Extracorporeal Shock Wave Not Provided SVCS PROV6185
01820 Services Provided: Gerontological Specialty Not Provided SVCS PROV6190
02020 Services Provided: ICU Neonatal Not Provided SVCS PROV6195
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Line Line Description TypeValue Field Name
02520 Services Provided: ICU Pediatric Not Provided SVCS PROV6200
03120 Services Provided: ICU Surgical Not Provided SVCS PROV6205
02000 Services Provided: Magnetic Resonance Imaging Provided under Arrangement SVCS PROV6210
02060 Services Provided: Neurosurgical Services Not Provided SVCS PROV6215
02220 Services Provided: Ophthalmic Surgery Not Provided SVCS PROV6220
02280 Services Provided: Orthopedic Surgery Not Provided SVCS PROV6225
02540 Services Provided: PET Scan Services Not Provided SVCS PROV6230
01740 Services Provided: Psychiatric - Emergency Not Provided SVCS PROV6235
02740 Services Provided: Psychiatric Child/Adolescent Not Provided SVCS PROV6240
01780 Services Provided: Psychiatric - Forensic Not Provided SVCS PROV6245
01800 Services Provided: Psychiatric - Geriatric Not Provided SVCS PROV6250
02440 Services Provided: Psychiatric - Outpatient Not Provided SVCS PROV6255
02870 Services Provided: Reconstructive Surgery Not Provided SVCS PROV6260
02460 Services Provided: Rehabilitation Outpatient Not Provided SVCS PROV6265
01420 Services Provided: CARF Inpatient Rehabilitation C Not Provided SVCS PROV6270
01950 Services Provided: Transplant Center (Medicare Cer Not Provided SVCS PROV6275
03280 Services Provided: Urgent Care Center Services Not Provided SVCS PROV6280
03770 Medical Technologist Count 0 FTES PROV6290
03840 Nuclear Medicine Technician Count 0 FTES PROV6295
04310 Psychologist Count 0 FTES PROV6300
04440 Radiology Technician Count 1 FTES PROV6305
00840 Fax Phone Number PROV9015
04230 Physician Assistants (PA) 0 PROV9020
00330 CBSA Urban Rural Indicator U SSAMSASZ
102000
A G HOLLEY STATE HOSPITAL
LANTANA, FL 33465
00320 FIPS County Code 12099 FIPCNTY
00310 FIPS State Code 12 FIPSTATE
00280 Type of Action Code 2 PR201301
00370 Affiliated Resident Program: Allopathic N PR201302
00380 Affiliated Resident Program: Dental N PR201303
00390 Affiliated Resident Program: Osteopathic N PR201304
00400 Affiliated Resident Program: Other N PR201305
01380 Services: Cardiac Catheterization Lab Code 0 PR201314
00340 Accreditation Effective Date DATE PROV0000
00350 Accreditation Expiration Date DATE PROV0005
00360 Accreditation Type Code None PROV0010
00020 Provider Category Code Hospital PROV0075
00010 Provider Category Subtype Code Long Term PROV0085
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Line Line Description TypeValue Field Name
00030 Change of Ownership Count 0 PROV0095
00040 Change of Ownership Date DATE PROV0100
00060 Compliance: Plan of Correction N PROV0220
00750 Compliance: Life Safety Code N CMPL PROV0240
00770 Compliance: Scope of Service N CMPL PROV0280
00780 Compliance: Technical Personnel Waiver N CMPL PROV0285
00720 Compliance: 24 Hour Registered Nurse N CMPL PROV0290
00090 Cross Ref Provider Number CODE PROV0300
04850 Date of Validation Survey DATE PROV0450
00110 Eligibility Switch Yes PROV0455
00850 Fiscal Year Ending Date 0630 PROV0485
00100 Certification Date 10/09/2009 DATE PROV0500
00130 Intermediary Carrier Code 09101 PROV0605
00930 Medical School Affiliation Limited PROV0645
00140 Medicare or Medicaid Vendor Number 010261000 CODE PROV0655
00990 Meets 1861 Definition N CMPL PROV0670
01000 Type of Non-Participating Provider PROV0690
00630 Beds-Total 100 BEDS PROV0740
00490 Beds - Total Certified 100 BEDS PROV0755
03490 Certified Registered Nurse Anesthetists (CRNA) 0 FTES PROV0760
03530 Dietitians 1 FTES PROV0820
04460 Respiratory Therapists 1 FTES PROV0950
03670 Licensed Practical/Vocational Nurses 5 FTES PROV0955
03750 Medical Social Workers 0 FTES PROV0975
03880 Nurse Practitioners 0 FTES PROV1015
03920 Occupational Therapists 0 FTES PROV1050
03430 Other Personnel 128 FTES PROV1075
04450 Registered Pharmacists 1 FTES PROV1100
04210 Physicians 3 FTES PROV1110
04330 Physical Therapists 0 FTES PROV1125
04470 Registered Nurses 12 FTES PROV1145
04270 Physicians (Residents) 0 FTES PROV1165
04640 Speech Pathologist or Audiologist 0 FTES PROV1220
00480 Regional Override # 1 (Number Beds) No PROV1545
03380 Regional Override # 2 (Staffing) No PROV1550
01010 Regional Override # 3 (Nurse - Bed) No PROV1555
00150 Participation Date 07/01/1966 DATE PROV1565
01080 Program Participation 3 PROV1570
00250 Telephone Number 5615825666 PROV1605
00160 Prior Change of Ownership Date DATE PROV1615
00170 Intermediary Carrier Prior Code 00090 CODE PROV1620
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Line Line Description TypeValue Field Name
00950 Medicare or Medicaid Participating Provider Switch Y PROV1670
00180 Provider Number 102000 CODE PROV1680
01100 Psychiatric Unit Bed Count 0 BEDS PROV1690
01110 Psychiatric Unit Effective Date DATE PROV1695
01120 Psychiatric Unit Switch No PROV1700
01130 Psychiatric Unit Termination Code PROV1705
01140 Psychiatric Unit Termination Date DATE PROV1710
00190 Region Code Atlanta PROV1725
01150 Rehabilitation Unit Bed Count 0 BEDS PROV1730
01160 Rehabilitation Unit Effective Date DATE PROV1735
01170 Rehabilitation Unit Switch No PROV1740
01180 Rehabilitation Unit Termination Code PROV1745
01190 Rehabilitation Unit Termination Date DATE PROV1750
01200 Related Provider Number CODE PROV1755
00200 Skeleton Record Switch N PROV2045
01210 Services Provided: Acute Renal Dialysis Not Provided SVCS PROV2055
01260 Services Provided: Alcohol and/or Drug Not Provided SVCS PROV2065
01280 Services Provided: Anesthesia Not Provided SVCS PROV2070
01360 Services Provided: Burn Care Unit Not Provided SVCS PROV2090
01460 Services Provided: Chiropractic Not Provided SVCS PROV2100
01530 Services Provided: ICU Cardiac (non-surgical) Not Provided SVCS PROV2110
01580 Services Provided: Dental Provided under Arrangement SVCS PROV2120
01670 Services Provided: Dietary Provided by Staff SVCS PROV2130
01930 Services Provided: ICU Medical/Surgical Not Provided SVCS PROV2185
01880 Services Provided: Inpatient Surgical Not Provided SVCS PROV2190
01510 Services Provided: Clinical Laboratory 0 SVCS PROV2200
02040 Services Provided: Neonatal Nursery Not Provided SVCS PROV2235
02100 Services Provided: Nuclear Medicine Not Provided SVCS PROV2245
02200 Services Provided: Obstetrics Not Provided SVCS PROV2265
02360 Services Provided: Occupational Therapy Not Provided SVCS PROV2270
01400 Services Provided: Cardiac - Thoracic Surgery Not Provided SVCS PROV2285
02240 Services Provided: Optometric Not Provided SVCS PROV2295
02260 Services Provided: Operating Rooms Not Provided SVCS PROV2300
02080 Services Provided: Organ Transplant (Not Medicare Not Provided SVCS PROV2315
02420 Services Provided: Outpatient Not Provided SVCS PROV2350
02480 Services Provided: Outpatient Surgery Not Provided SVCS PROV2355
02500 Services Provided: Pediatric Provided by Staff and Arrangement
SVCS PROV2360
00430 Services Provided: Pharmacy Not Provided SVCS PROV2365
02820 Services Provided: Physical Therapy Not Provided SVCS PROV2370
02720 Services Provided: Postoperative Recovery Room Not Provided SVCS PROV2410
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Line Line Description TypeValue Field Name
01230 Services Provided: Psychiatric - Adult Inpatient Not Provided SVCS PROV2415
01650 Services Provided: Radiology (Diagnostic) Provided under Arrangement SVCS PROV2440
03230 Services Provided: Radiology (Therapeutic) Not Provided SVCS PROV2445
02920 Services Provided: Respiratory Care Provided by Staff and Arrangement
SVCS PROV2455
01630 Services Provided: Trauma Center (Designated) Not Provided SVCS PROV2475
02980 Services Provided: Social Provided by Staff SVCS PROV2485
03060 Services Provided: Speech Pathology Not Provided SVCS PROV2505
00080 SSA County Code 490 PROV2695
00220 SSA State Code 10 PROV2700
00230 State Region Code LAN PROV2710
00070 Compliance: Status Not In Compliance PROV2715
04790 Swing Bed Switch Swing Bed service is approved PROV2795
04800 Swing Bed Size Code 49 or fewer swing beds PROV2800
00290 General Type of Control Code Government - State PROV2885
00410 Type of Facility Long - Term PROV2890
00300 ZIP Code 33465 PROV2905
00210 State Abbreviation FL PROV3230
00790 Current Survey Ever Swing Bed Yes PROV3550
00270 Termination Date / Expiration Date 1 08/01/2012 DATE PROV4500
00260 Termination Code 1 Voluntary - Merge,Close PROV4770
01310 Services Provided: Audiology Not Provided SVCS PROV6160
01440 Services Provided: Chemotherapy Not Provided SVCS PROV6170
01560 Services Provided: CT Scanner Not Provided SVCS PROV6175
01720 Services Provided: Emergency Dept(Dedicated) Not Provided SVCS PROV6180
01760 Services Provided: Extracorporeal Shock Wave Not Provided SVCS PROV6185
01820 Services Provided: Gerontological Specialty Not Provided SVCS PROV6190
02020 Services Provided: ICU Neonatal Not Provided SVCS PROV6195
02520 Services Provided: ICU Pediatric Not Provided SVCS PROV6200
03120 Services Provided: ICU Surgical Not Provided SVCS PROV6205
02000 Services Provided: Magnetic Resonance Imaging Not Provided SVCS PROV6210
02060 Services Provided: Neurosurgical Services Not Provided SVCS PROV6215
02220 Services Provided: Ophthalmic Surgery Not Provided SVCS PROV6220
02280 Services Provided: Orthopedic Surgery Not Provided SVCS PROV6225
02540 Services Provided: PET Scan Services Not Provided SVCS PROV6230
01740 Services Provided: Psychiatric - Emergency Not Provided SVCS PROV6235
02740 Services Provided: Psychiatric Child/Adolescent Not Provided SVCS PROV6240
01780 Services Provided: Psychiatric - Forensic Not Provided SVCS PROV6245
01800 Services Provided: Psychiatric - Geriatric Not Provided SVCS PROV6250
02440 Services Provided: Psychiatric - Outpatient Not Provided SVCS PROV6255
02870 Services Provided: Reconstructive Surgery Not Provided SVCS PROV6260
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Line Line Description TypeValue Field Name
02460 Services Provided: Rehabilitation Outpatient Not Provided SVCS PROV6265
01420 Services Provided: CARF Inpatient Rehabilitation C Not Provided SVCS PROV6270
01950 Services Provided: Transplant Center (Medicare Cer Not Provided SVCS PROV6275
03280 Services Provided: Urgent Care Center Services Not Provided SVCS PROV6280
03770 Medical Technologist Count 0 FTES PROV6290
03840 Nuclear Medicine Technician Count 0 FTES PROV6295
04310 Psychologist Count 0 FTES PROV6300
04440 Radiology Technician Count 0 FTES PROV6305
00840 Fax Phone Number PROV9015
04230 Physician Assistants (PA) 2 PROV9020
00330 CBSA Urban Rural Indicator U SSAMSASZ
10065F
WEST PALM BEACH VA MEDICAL CENTER
WEST PALM BEACH, FL 33410
00320 FIPS County Code 12099 FIPCNTY
00310 FIPS State Code 12 FIPSTATE
00280 Type of Action Code 1 PR201301
00370 Affiliated Resident Program: Allopathic N PR201302
00380 Affiliated Resident Program: Dental N PR201303
00390 Affiliated Resident Program: Osteopathic N PR201304
00400 Affiliated Resident Program: Other N PR201305
01380 Services: Cardiac Catheterization Lab Code PR201314
00340 Accreditation Effective Date DATE PROV0000
00350 Accreditation Expiration Date DATE PROV0005
00360 Accreditation Type Code JCAHO PROV0010
00020 Provider Category Code Hospital PROV0075
00010 Provider Category Subtype Code PROV0085
00030 Change of Ownership Count 0 PROV0095
00040 Change of Ownership Date DATE PROV0100
00060 Compliance: Plan of Correction N PROV0220
00750 Compliance: Life Safety Code N CMPL PROV0240
00770 Compliance: Scope of Service N CMPL PROV0280
00780 Compliance: Technical Personnel Waiver N CMPL PROV0285
00720 Compliance: 24 Hour Registered Nurse N CMPL PROV0290
00090 Cross Ref Provider Number CODE PROV0300
04850 Date of Validation Survey DATE PROV0450
00110 Eligibility Switch No PROV0455
00850 Fiscal Year Ending Date PROV0485
00100 Certification Date 02/08/2000 DATE PROV0500
00130 Intermediary Carrier Code 00090 PROV0605
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Line Line Description TypeValue Field Name
00930 Medical School Affiliation PROV0645
00140 Medicare or Medicaid Vendor Number CODE PROV0655
00990 Meets 1861 Definition N CMPL PROV0670
01000 Type of Non-Participating Provider Emergency Hospital - Federal PROV0690
00630 Beds-Total 192 BEDS PROV0740
00490 Beds - Total Certified 192 BEDS PROV0755
03490 Certified Registered Nurse Anesthetists (CRNA) 0 FTES PROV0760
03530 Dietitians 0 FTES PROV0820
04460 Respiratory Therapists 0 FTES PROV0950
03670 Licensed Practical/Vocational Nurses 0 FTES PROV0955
03750 Medical Social Workers 0 FTES PROV0975
03880 Nurse Practitioners 0 FTES PROV1015
03920 Occupational Therapists 0 FTES PROV1050
03430 Other Personnel 0 FTES PROV1075
04450 Registered Pharmacists 0 FTES PROV1100
04210 Physicians 0 FTES PROV1110
04330 Physical Therapists 0 FTES PROV1125
04470 Registered Nurses 0 FTES PROV1145
04270 Physicians (Residents) 0 FTES PROV1165
04640 Speech Pathologist or Audiologist 0 FTES PROV1220
00480 Regional Override # 1 (Number Beds) No PROV1545
03380 Regional Override # 2 (Staffing) No PROV1550
01010 Regional Override # 3 (Nurse - Bed) No PROV1555
00150 Participation Date 02/08/2000 DATE PROV1565
01080 Program Participation PROV1570
00250 Telephone Number 5618828262 PROV1605
00160 Prior Change of Ownership Date DATE PROV1615
00170 Intermediary Carrier Prior Code 00010 CODE PROV1620
00950 Medicare or Medicaid Participating Provider Switch N PROV1670
00180 Provider Number 10065F CODE PROV1680
01100 Psychiatric Unit Bed Count 0 BEDS PROV1690
01110 Psychiatric Unit Effective Date DATE PROV1695
01120 Psychiatric Unit Switch No PROV1700
01130 Psychiatric Unit Termination Code PROV1705
01140 Psychiatric Unit Termination Date DATE PROV1710
00190 Region Code Atlanta PROV1725
01150 Rehabilitation Unit Bed Count 0 BEDS PROV1730
01160 Rehabilitation Unit Effective Date DATE PROV1735
01170 Rehabilitation Unit Switch No PROV1740
01180 Rehabilitation Unit Termination Code PROV1745
01190 Rehabilitation Unit Termination Date DATE PROV1750
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Line Line Description TypeValue Field Name
01200 Related Provider Number CODE PROV1755
00200 Skeleton Record Switch Skeleton record with limited data PROV2045
01210 Services Provided: Acute Renal Dialysis SVCS PROV2055
01260 Services Provided: Alcohol and/or Drug SVCS PROV2065
01280 Services Provided: Anesthesia SVCS PROV2070
01360 Services Provided: Burn Care Unit SVCS PROV2090
01460 Services Provided: Chiropractic SVCS PROV2100
01530 Services Provided: ICU Cardiac (non-surgical) SVCS PROV2110
01580 Services Provided: Dental SVCS PROV2120
01670 Services Provided: Dietary SVCS PROV2130
01930 Services Provided: ICU Medical/Surgical SVCS PROV2185
01880 Services Provided: Inpatient Surgical SVCS PROV2190
01510 Services Provided: Clinical Laboratory SVCS PROV2200
02040 Services Provided: Neonatal Nursery SVCS PROV2235
02100 Services Provided: Nuclear Medicine SVCS PROV2245
02200 Services Provided: Obstetrics SVCS PROV2265
02360 Services Provided: Occupational Therapy SVCS PROV2270
01400 Services Provided: Cardiac - Thoracic Surgery SVCS PROV2285
02240 Services Provided: Optometric SVCS PROV2295
02260 Services Provided: Operating Rooms SVCS PROV2300
02080 Services Provided: Organ Transplant (Not Medicare SVCS PROV2315
02420 Services Provided: Outpatient SVCS PROV2350
02480 Services Provided: Outpatient Surgery SVCS PROV2355
02500 Services Provided: Pediatric SVCS PROV2360
00430 Services Provided: Pharmacy SVCS PROV2365
02820 Services Provided: Physical Therapy SVCS PROV2370
02720 Services Provided: Postoperative Recovery Room SVCS PROV2410
01230 Services Provided: Psychiatric - Adult Inpatient SVCS PROV2415
01650 Services Provided: Radiology (Diagnostic) SVCS PROV2440
03230 Services Provided: Radiology (Therapeutic) SVCS PROV2445
02920 Services Provided: Respiratory Care SVCS PROV2455
01630 Services Provided: Trauma Center (Designated) SVCS PROV2475
02980 Services Provided: Social SVCS PROV2485
03060 Services Provided: Speech Pathology SVCS PROV2505
00080 SSA County Code 490 PROV2695
00220 SSA State Code 10 PROV2700
00230 State Region Code LAU PROV2710
00070 Compliance: Status PROV2715
04790 Swing Bed Switch Swing Bed service not approved PROV2795
04800 Swing Bed Size Code PROV2800
00290 General Type of Control Code Not Provider by Hospital PROV2885
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Line Line Description TypeValue Field Name
00410 Type of Facility 01 PROV2890
00300 ZIP Code 33410 PROV2905
00210 State Abbreviation FL PROV3230
00790 Current Survey Ever Swing Bed No PROV3550
00270 Termination Date / Expiration Date 1 DATE PROV4500
00260 Termination Code 1 Active PROV4770
01310 Services Provided: Audiology SVCS PROV6160
01440 Services Provided: Chemotherapy SVCS PROV6170
01560 Services Provided: CT Scanner SVCS PROV6175
01720 Services Provided: Emergency Dept(Dedicated) SVCS PROV6180
01760 Services Provided: Extracorporeal Shock Wave SVCS PROV6185
01820 Services Provided: Gerontological Specialty SVCS PROV6190
02020 Services Provided: ICU Neonatal SVCS PROV6195
02520 Services Provided: ICU Pediatric SVCS PROV6200
03120 Services Provided: ICU Surgical SVCS PROV6205
02000 Services Provided: Magnetic Resonance Imaging SVCS PROV6210
02060 Services Provided: Neurosurgical Services SVCS PROV6215
02220 Services Provided: Ophthalmic Surgery SVCS PROV6220
02280 Services Provided: Orthopedic Surgery SVCS PROV6225
02540 Services Provided: PET Scan Services SVCS PROV6230
01740 Services Provided: Psychiatric - Emergency SVCS PROV6235
02740 Services Provided: Psychiatric Child/Adolescent SVCS PROV6240
01780 Services Provided: Psychiatric - Forensic SVCS PROV6245
01800 Services Provided: Psychiatric - Geriatric SVCS PROV6250
02440 Services Provided: Psychiatric - Outpatient SVCS PROV6255
02870 Services Provided: Reconstructive Surgery SVCS PROV6260
02460 Services Provided: Rehabilitation Outpatient SVCS PROV6265
01420 Services Provided: CARF Inpatient Rehabilitation C SVCS PROV6270
01950 Services Provided: Transplant Center (Medicare Cer SVCS PROV6275
03280 Services Provided: Urgent Care Center Services SVCS PROV6280
03770 Medical Technologist Count 0 FTES PROV6290
03840 Nuclear Medicine Technician Count 0 FTES PROV6295
04310 Psychologist Count 0 FTES PROV6300
04440 Radiology Technician Count 0 FTES PROV6305
00840 Fax Phone Number PROV9015
04230 Physician Assistants (PA) 0 PROV9020
00330 CBSA Urban Rural Indicator U SSAMSASZ
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Line Line Description TypeValue Field Name
100310
KINDRED HOSPITAL THE PALM BEACHES
RIVIERA BEACH, FL 33418
00320 FIPS County Code 12099 FIPCNTY
00310 FIPS State Code 12 FIPSTATE
00280 Type of Action Code 1 PR201301
00370 Affiliated Resident Program: Allopathic N PR201302
00380 Affiliated Resident Program: Dental N PR201303
00390 Affiliated Resident Program: Osteopathic N PR201304
00400 Affiliated Resident Program: Other N PR201305
01380 Services: Cardiac Catheterization Lab Code 0 PR201314
00340 Accreditation Effective Date DATE PROV0000
00350 Accreditation Expiration Date DATE PROV0005
00360 Accreditation Type Code None PROV0010
00020 Provider Category Code Hospital PROV0075
00010 Provider Category Subtype Code Short Term PROV0085
00030 Change of Ownership Count 0 PROV0095
00040 Change of Ownership Date DATE PROV0100
00060 Compliance: Plan of Correction Y PROV0220
00750 Compliance: Life Safety Code N CMPL PROV0240
00770 Compliance: Scope of Service N CMPL PROV0280
00780 Compliance: Technical Personnel Waiver N CMPL PROV0285
00720 Compliance: 24 Hour Registered Nurse N CMPL PROV0290
00090 Cross Ref Provider Number 102025 CODE PROV0300
04850 Date of Validation Survey DATE PROV0450
00110 Eligibility Switch Yes PROV0455
00850 Fiscal Year Ending Date 0531 PROV0485
00100 Certification Date 10/29/2008 DATE PROV0500
00130 Intermediary Carrier Code 00090 PROV0605
00930 Medical School Affiliation No Affiliation PROV0645
00140 Medicare or Medicaid Vendor Number CODE PROV0655
00990 Meets 1861 Definition N CMPL PROV0670
01000 Type of Non-Participating Provider PROV0690
00630 Beds-Total 70 BEDS PROV0740
00490 Beds - Total Certified 70 BEDS PROV0755
03490 Certified Registered Nurse Anesthetists (CRNA) 0 FTES PROV0760
03530 Dietitians 1 FTES PROV0820
04460 Respiratory Therapists 5 FTES PROV0950
03670 Licensed Practical/Vocational Nurses 0 FTES PROV0955
03750 Medical Social Workers 0 FTES PROV0975
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Line Line Description TypeValue Field Name
03880 Nurse Practitioners 0 FTES PROV1015
03920 Occupational Therapists 0 FTES PROV1050
03430 Other Personnel 13 FTES PROV1075
04450 Registered Pharmacists 0 FTES PROV1100
04210 Physicians 0 FTES PROV1110
04330 Physical Therapists 0 FTES PROV1125
04470 Registered Nurses 18 FTES PROV1145
04270 Physicians (Residents) 0 FTES PROV1165
04640 Speech Pathologist or Audiologist 0 FTES PROV1220
00480 Regional Override # 1 (Number Beds) No PROV1545
03380 Regional Override # 2 (Staffing) No PROV1550
01010 Regional Override # 3 (Nurse - Bed) No PROV1555
00150 Participation Date 11/20/2008 DATE PROV1565
01080 Program Participation 3 PROV1570
00250 Telephone Number 5618400754 PROV1605
00160 Prior Change of Ownership Date DATE PROV1615
00170 Intermediary Carrier Prior Code CODE PROV1620
00950 Medicare or Medicaid Participating Provider Switch Y PROV1670
00180 Provider Number 100310 CODE PROV1680
01100 Psychiatric Unit Bed Count 0 BEDS PROV1690
01110 Psychiatric Unit Effective Date DATE PROV1695
01120 Psychiatric Unit Switch No PROV1700
01130 Psychiatric Unit Termination Code PROV1705
01140 Psychiatric Unit Termination Date DATE PROV1710
00190 Region Code Atlanta PROV1725
01150 Rehabilitation Unit Bed Count 0 BEDS PROV1730
01160 Rehabilitation Unit Effective Date DATE PROV1735
01170 Rehabilitation Unit Switch No PROV1740
01180 Rehabilitation Unit Termination Code PROV1745
01190 Rehabilitation Unit Termination Date DATE PROV1750
01200 Related Provider Number CODE PROV1755
00200 Skeleton Record Switch N PROV2045
01210 Services Provided: Acute Renal Dialysis Provided under Arrangement SVCS PROV2055
01260 Services Provided: Alcohol and/or Drug Not Provided SVCS PROV2065
01280 Services Provided: Anesthesia Provided under Arrangement SVCS PROV2070
01360 Services Provided: Burn Care Unit Not Provided SVCS PROV2090
01460 Services Provided: Chiropractic Not Provided SVCS PROV2100
01530 Services Provided: ICU Cardiac (non-surgical) Not Provided SVCS PROV2110
01580 Services Provided: Dental Not Provided SVCS PROV2120
01670 Services Provided: Dietary Provided by Staff SVCS PROV2130
01930 Services Provided: ICU Medical/Surgical Provided by Staff SVCS PROV2185
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Line Line Description TypeValue Field Name
01880 Services Provided: Inpatient Surgical Provided by Staff and Arrangement
SVCS PROV2190
01510 Services Provided: Clinical Laboratory 3 SVCS PROV2200
02040 Services Provided: Neonatal Nursery Not Provided SVCS PROV2235
02100 Services Provided: Nuclear Medicine Provided under Arrangement SVCS PROV2245
02200 Services Provided: Obstetrics Not Provided SVCS PROV2265
02360 Services Provided: Occupational Therapy Provided under Arrangement SVCS PROV2270
01400 Services Provided: Cardiac - Thoracic Surgery Not Provided SVCS PROV2285
02240 Services Provided: Optometric Not Provided SVCS PROV2295
02260 Services Provided: Operating Rooms Provided by Staff and Arrangement
SVCS PROV2300
02080 Services Provided: Organ Transplant (Not Medicare Not Provided SVCS PROV2315
02420 Services Provided: Outpatient Not Provided SVCS PROV2350
02480 Services Provided: Outpatient Surgery Not Provided SVCS PROV2355
02500 Services Provided: Pediatric Not Provided SVCS PROV2360
00430 Services Provided: Pharmacy Provided under Arrangement SVCS PROV2365
02820 Services Provided: Physical Therapy Provided under Arrangement SVCS PROV2370
02720 Services Provided: Postoperative Recovery Room Provided by Staff and Arrangement
SVCS PROV2410
01230 Services Provided: Psychiatric - Adult Inpatient Not Provided SVCS PROV2415
01650 Services Provided: Radiology (Diagnostic) Provided by Staff and Arrangement
SVCS PROV2440
03230 Services Provided: Radiology (Therapeutic) Not Provided SVCS PROV2445
02920 Services Provided: Respiratory Care Provided by Staff SVCS PROV2455
01630 Services Provided: Trauma Center (Designated) Not Provided SVCS PROV2475
02980 Services Provided: Social Provided by Staff SVCS PROV2485
03060 Services Provided: Speech Pathology Provided under Arrangement SVCS PROV2505
00080 SSA County Code 490 PROV2695
00220 SSA State Code 10 PROV2700
00230 State Region Code LAU PROV2710
00070 Compliance: Status In Compliance PROV2715
04790 Swing Bed Switch Swing Bed service not approved PROV2795
04800 Swing Bed Size Code PROV2800
00290 General Type of Control Code Proprietary PROV2885
00410 Type of Facility Short - Term PROV2890
00300 ZIP Code 33418 PROV2905
00210 State Abbreviation FL PROV3230
00790 Current Survey Ever Swing Bed No PROV3550
00270 Termination Date / Expiration Date 1 05/31/2009 DATE PROV4500
00260 Termination Code 1 Other - Status Change PROV4770
01310 Services Provided: Audiology Not Provided SVCS PROV6160
01440 Services Provided: Chemotherapy Not Provided SVCS PROV6170
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Line Line Description TypeValue Field Name
01560 Services Provided: CT Scanner Provided by Staff SVCS PROV6175
01720 Services Provided: Emergency Dept(Dedicated) Not Provided SVCS PROV6180
01760 Services Provided: Extracorporeal Shock Wave Not Provided SVCS PROV6185
01820 Services Provided: Gerontological Specialty Not Provided SVCS PROV6190
02020 Services Provided: ICU Neonatal Not Provided SVCS PROV6195
02520 Services Provided: ICU Pediatric Not Provided SVCS PROV6200
03120 Services Provided: ICU Surgical Not Provided SVCS PROV6205
02000 Services Provided: Magnetic Resonance Imaging Provided under Arrangement SVCS PROV6210
02060 Services Provided: Neurosurgical Services Not Provided SVCS PROV6215
02220 Services Provided: Ophthalmic Surgery Not Provided SVCS PROV6220
02280 Services Provided: Orthopedic Surgery Not Provided SVCS PROV6225
02540 Services Provided: PET Scan Services Not Provided SVCS PROV6230
01740 Services Provided: Psychiatric - Emergency Not Provided SVCS PROV6235
02740 Services Provided: Psychiatric Child/Adolescent Not Provided SVCS PROV6240
01780 Services Provided: Psychiatric - Forensic Not Provided SVCS PROV6245
01800 Services Provided: Psychiatric - Geriatric Not Provided SVCS PROV6250
02440 Services Provided: Psychiatric - Outpatient Not Provided SVCS PROV6255
02870 Services Provided: Reconstructive Surgery Not Provided SVCS PROV6260
02460 Services Provided: Rehabilitation Outpatient Not Provided SVCS PROV6265
01420 Services Provided: CARF Inpatient Rehabilitation C Not Provided SVCS PROV6270
01950 Services Provided: Transplant Center (Medicare Cer Not Provided SVCS PROV6275
03280 Services Provided: Urgent Care Center Services Not Provided SVCS PROV6280
03770 Medical Technologist Count 0 FTES PROV6290
03840 Nuclear Medicine Technician Count 0 FTES PROV6295
04310 Psychologist Count 0 FTES PROV6300
04440 Radiology Technician Count 1 FTES PROV6305
00840 Fax Phone Number 5618420271 PROV9015
04230 Physician Assistants (PA) 0 PROV9020
00330 CBSA Urban Rural Indicator U SSAMSASZ
100309
SELECT SPECIALTY HOSPITAL - PALM BEACH, INC
LAKE WORTH, FL 33461
00320 FIPS County Code 12099 FIPCNTY
00310 FIPS State Code 12 FIPSTATE
00280 Type of Action Code 1 PR201301
00370 Affiliated Resident Program: Allopathic N PR201302
00380 Affiliated Resident Program: Dental N PR201303
00390 Affiliated Resident Program: Osteopathic N PR201304
00400 Affiliated Resident Program: Other N PR201305
01380 Services: Cardiac Catheterization Lab Code 0 PR201314
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Line Line Description TypeValue Field Name
00340 Accreditation Effective Date DATE PROV0000
00350 Accreditation Expiration Date DATE PROV0005
00360 Accreditation Type Code None PROV0010
00020 Provider Category Code Hospital PROV0075
00010 Provider Category Subtype Code Short Term PROV0085
00030 Change of Ownership Count 0 PROV0095
00040 Change of Ownership Date DATE PROV0100
00060 Compliance: Plan of Correction N PROV0220
00750 Compliance: Life Safety Code N CMPL PROV0240
00770 Compliance: Scope of Service N CMPL PROV0280
00780 Compliance: Technical Personnel Waiver N CMPL PROV0285
00720 Compliance: 24 Hour Registered Nurse N CMPL PROV0290
00090 Cross Ref Provider Number CODE PROV0300
04850 Date of Validation Survey DATE PROV0450
00110 Eligibility Switch Yes PROV0455
00850 Fiscal Year Ending Date 1130 PROV0485
00100 Certification Date 05/06/2008 DATE PROV0500
00130 Intermediary Carrier Code 00090 PROV0605
00930 Medical School Affiliation No Affiliation PROV0645
00140 Medicare or Medicaid Vendor Number CODE PROV0655
00990 Meets 1861 Definition N CMPL PROV0670
01000 Type of Non-Participating Provider PROV0690
00630 Beds-Total 60 BEDS PROV0740
00490 Beds - Total Certified 60 BEDS PROV0755
03490 Certified Registered Nurse Anesthetists (CRNA) 0 FTES PROV0760
03530 Dietitians 1 FTES PROV0820
04460 Respiratory Therapists 5 FTES PROV0950
03670 Licensed Practical/Vocational Nurses 0 FTES PROV0955
03750 Medical Social Workers 0 FTES PROV0975
03880 Nurse Practitioners 0 FTES PROV1015
03920 Occupational Therapists 0 FTES PROV1050
03430 Other Personnel 28 FTES PROV1075
04450 Registered Pharmacists 2 FTES PROV1100
04210 Physicians 0 FTES PROV1110
04330 Physical Therapists 1 FTES PROV1125
04470 Registered Nurses 13 FTES PROV1145
04270 Physicians (Residents) 0 FTES PROV1165
04640 Speech Pathologist or Audiologist 0 FTES PROV1220
00480 Regional Override # 1 (Number Beds) No PROV1545
03380 Regional Override # 2 (Staffing) No PROV1550
01010 Regional Override # 3 (Nurse - Bed) No PROV1555
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Line Line Description TypeValue Field Name
00150 Participation Date 05/06/2008 DATE PROV1565
01080 Program Participation 3 PROV1570
00250 Telephone Number 5613577200 PROV1605
00160 Prior Change of Ownership Date DATE PROV1615
00170 Intermediary Carrier Prior Code CODE PROV1620
00950 Medicare or Medicaid Participating Provider Switch Y PROV1670
00180 Provider Number 100309 CODE PROV1680
01100 Psychiatric Unit Bed Count 0 BEDS PROV1690
01110 Psychiatric Unit Effective Date DATE PROV1695
01120 Psychiatric Unit Switch No PROV1700
01130 Psychiatric Unit Termination Code PROV1705
01140 Psychiatric Unit Termination Date DATE PROV1710
00190 Region Code Atlanta PROV1725
01150 Rehabilitation Unit Bed Count 0 BEDS PROV1730
01160 Rehabilitation Unit Effective Date DATE PROV1735
01170 Rehabilitation Unit Switch No PROV1740
01180 Rehabilitation Unit Termination Code PROV1745
01190 Rehabilitation Unit Termination Date DATE PROV1750
01200 Related Provider Number CODE PROV1755
00200 Skeleton Record Switch N PROV2045
01210 Services Provided: Acute Renal Dialysis Not Provided SVCS PROV2055
01260 Services Provided: Alcohol and/or Drug Not Provided SVCS PROV2065
01280 Services Provided: Anesthesia Not Provided SVCS PROV2070
01360 Services Provided: Burn Care Unit Not Provided SVCS PROV2090
01460 Services Provided: Chiropractic Not Provided SVCS PROV2100
01530 Services Provided: ICU Cardiac (non-surgical) Not Provided SVCS PROV2110
01580 Services Provided: Dental Not Provided SVCS PROV2120
01670 Services Provided: Dietary Provided by Staff SVCS PROV2130
01930 Services Provided: ICU Medical/Surgical Provided by Staff SVCS PROV2185
01880 Services Provided: Inpatient Surgical Provided by Staff SVCS PROV2190
01510 Services Provided: Clinical Laboratory 3 SVCS PROV2200
02040 Services Provided: Neonatal Nursery Not Provided SVCS PROV2235
02100 Services Provided: Nuclear Medicine Not Provided SVCS PROV2245
02200 Services Provided: Obstetrics Not Provided SVCS PROV2265
02360 Services Provided: Occupational Therapy Provided by Staff and Arrangement
SVCS PROV2270
01400 Services Provided: Cardiac - Thoracic Surgery Not Provided SVCS PROV2285
02240 Services Provided: Optometric Not Provided SVCS PROV2295
02260 Services Provided: Operating Rooms Not Provided SVCS PROV2300
02080 Services Provided: Organ Transplant (Not Medicare Not Provided SVCS PROV2315
02420 Services Provided: Outpatient Not Provided SVCS PROV2350
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Line Line Description TypeValue Field Name
02480 Services Provided: Outpatient Surgery Not Provided SVCS PROV2355
02500 Services Provided: Pediatric Not Provided SVCS PROV2360
00430 Services Provided: Pharmacy Provided by Staff and Arrangement
SVCS PROV2365
02820 Services Provided: Physical Therapy Provided by Staff and Arrangement
SVCS PROV2370
02720 Services Provided: Postoperative Recovery Room Not Provided SVCS PROV2410
01230 Services Provided: Psychiatric - Adult Inpatient Not Provided SVCS PROV2415
01650 Services Provided: Radiology (Diagnostic) Provided by Staff and Arrangement
SVCS PROV2440
03230 Services Provided: Radiology (Therapeutic) Not Provided SVCS PROV2445
02920 Services Provided: Respiratory Care Provided by Staff SVCS PROV2455
01630 Services Provided: Trauma Center (Designated) Not Provided SVCS PROV2475
02980 Services Provided: Social Not Provided SVCS PROV2485
03060 Services Provided: Speech Pathology Provided by Staff and Arrangement
SVCS PROV2505
00080 SSA County Code 490 PROV2695
00220 SSA State Code 10 PROV2700
00230 State Region Code LAN PROV2710
00070 Compliance: Status In Compliance PROV2715
04790 Swing Bed Switch Swing Bed service not approved PROV2795
04800 Swing Bed Size Code PROV2800
00290 General Type of Control Code Proprietary PROV2885
00410 Type of Facility Short - Term PROV2890
00300 ZIP Code 33461 PROV2905
00210 State Abbreviation FL PROV3230
00790 Current Survey Ever Swing Bed No PROV3550
00270 Termination Date / Expiration Date 1 11/30/2008 DATE PROV4500
00260 Termination Code 1 Voluntary - Merge,Close PROV4770
01310 Services Provided: Audiology Not Provided SVCS PROV6160
01440 Services Provided: Chemotherapy Not Provided SVCS PROV6170
01560 Services Provided: CT Scanner Provided by Staff SVCS PROV6175
01720 Services Provided: Emergency Dept(Dedicated) Not Provided SVCS PROV6180
01760 Services Provided: Extracorporeal Shock Wave Not Provided SVCS PROV6185
01820 Services Provided: Gerontological Specialty Not Provided SVCS PROV6190
02020 Services Provided: ICU Neonatal Not Provided SVCS PROV6195
02520 Services Provided: ICU Pediatric Not Provided SVCS PROV6200
03120 Services Provided: ICU Surgical Not Provided SVCS PROV6205
02000 Services Provided: Magnetic Resonance Imaging Provided under Arrangement SVCS PROV6210
02060 Services Provided: Neurosurgical Services Not Provided SVCS PROV6215
02220 Services Provided: Ophthalmic Surgery Not Provided SVCS PROV6220
02280 Services Provided: Orthopedic Surgery Not Provided SVCS PROV6225
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Line Line Description TypeValue Field Name
02540 Services Provided: PET Scan Services Not Provided SVCS PROV6230
01740 Services Provided: Psychiatric - Emergency Not Provided SVCS PROV6235
02740 Services Provided: Psychiatric Child/Adolescent Not Provided SVCS PROV6240
01780 Services Provided: Psychiatric - Forensic Not Provided SVCS PROV6245
01800 Services Provided: Psychiatric - Geriatric Not Provided SVCS PROV6250
02440 Services Provided: Psychiatric - Outpatient Not Provided SVCS PROV6255
02870 Services Provided: Reconstructive Surgery Not Provided SVCS PROV6260
02460 Services Provided: Rehabilitation Outpatient Not Provided SVCS PROV6265
01420 Services Provided: CARF Inpatient Rehabilitation C Not Provided SVCS PROV6270
01950 Services Provided: Transplant Center (Medicare Cer Not Provided SVCS PROV6275
03280 Services Provided: Urgent Care Center Services Not Provided SVCS PROV6280
03770 Medical Technologist Count 0 FTES PROV6290
03840 Nuclear Medicine Technician Count 0 FTES PROV6295
04310 Psychologist Count 0 FTES PROV6300
04440 Radiology Technician Count 1 FTES PROV6305
00840 Fax Phone Number PROV9015
04230 Physician Assistants (PA) 0 PROV9020
00330 CBSA Urban Rural Indicator U SSAMSASZ
100288
ST MARY'S MEDICAL CENTER
WEST PALM BEACH, FL 33407
00320 FIPS County Code 12099 FIPCNTY
00310 FIPS State Code 12 FIPSTATE
00280 Type of Action Code 2 PR201301
00370 Affiliated Resident Program: Allopathic N PR201302
00380 Affiliated Resident Program: Dental N PR201303
00390 Affiliated Resident Program: Osteopathic N PR201304
00400 Affiliated Resident Program: Other N PR201305
01380 Services: Cardiac Catheterization Lab Code 1 PR201314
00340 Accreditation Effective Date 03/12/2010 DATE PROV0000
00350 Accreditation Expiration Date 03/11/2013 DATE PROV0005
00360 Accreditation Type Code JCAHO PROV0010
00020 Provider Category Code Hospital PROV0075
00010 Provider Category Subtype Code Short Term PROV0085
00030 Change of Ownership Count 1 PROV0095
00040 Change of Ownership Date DATE PROV0100
00060 Compliance: Plan of Correction N PROV0220
00750 Compliance: Life Safety Code N CMPL PROV0240
00770 Compliance: Scope of Service N CMPL PROV0280
00780 Compliance: Technical Personnel Waiver N CMPL PROV0285
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Line Line Description TypeValue Field Name
00720 Compliance: 24 Hour Registered Nurse N CMPL PROV0290
00090 Cross Ref Provider Number CODE PROV0300
04850 Date of Validation Survey DATE PROV0450
00110 Eligibility Switch Yes PROV0455
00850 Fiscal Year Ending Date 0531 PROV0485
00100 Certification Date 07/07/2001 DATE PROV0500
00130 Intermediary Carrier Code 52280 PROV0605
00930 Medical School Affiliation No Affiliation PROV0645
00140 Medicare or Medicaid Vendor Number 010148600 CODE PROV0655
00990 Meets 1861 Definition N CMPL PROV0670
01000 Type of Non-Participating Provider PROV0690
00630 Beds-Total 464 BEDS PROV0740
00490 Beds - Total Certified 464 BEDS PROV0755
03490 Certified Registered Nurse Anesthetists (CRNA) 0 FTES PROV0760
03530 Dietitians 6 FTES PROV0820
04460 Respiratory Therapists 46 FTES PROV0950
03670 Licensed Practical/Vocational Nurses 9 FTES PROV0955
03750 Medical Social Workers 2 FTES PROV0975
03880 Nurse Practitioners 3 FTES PROV1015
03920 Occupational Therapists 11 FTES PROV1050
03430 Other Personnel 623 FTES PROV1075
04450 Registered Pharmacists 17 FTES PROV1100
04210 Physicians 0 FTES PROV1110
04330 Physical Therapists 13 FTES PROV1125
04470 Registered Nurses 498 FTES PROV1145
04270 Physicians (Residents) 0 FTES PROV1165
04640 Speech Pathologist or Audiologist 4 FTES PROV1220
00480 Regional Override # 1 (Number Beds) No PROV1545
03380 Regional Override # 2 (Staffing) No PROV1550
01010 Regional Override # 3 (Nurse - Bed) No PROV1555
00150 Participation Date 07/06/2001 DATE PROV1565
01080 Program Participation 3 PROV1570
00250 Telephone Number 5618406202 PROV1605
00160 Prior Change of Ownership Date DATE PROV1615
00170 Intermediary Carrier Prior Code CODE PROV1620
00950 Medicare or Medicaid Participating Provider Switch Y PROV1670
00180 Provider Number 100288 CODE PROV1680
01100 Psychiatric Unit Bed Count 40 BEDS PROV1690
01110 Psychiatric Unit Effective Date 06/01/2011 DATE PROV1695
01120 Psychiatric Unit Switch Yes PROV1700
01130 Psychiatric Unit Termination Code Active PROV1705
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Line Line Description TypeValue Field Name
01140 Psychiatric Unit Termination Date DATE PROV1710
00190 Region Code Atlanta PROV1725
01150 Rehabilitation Unit Bed Count 50 BEDS PROV1730
01160 Rehabilitation Unit Effective Date 06/01/2011 DATE PROV1735
01170 Rehabilitation Unit Switch Yes PROV1740
01180 Rehabilitation Unit Termination Code Active PROV1745
01190 Rehabilitation Unit Termination Date DATE PROV1750
01200 Related Provider Number CODE PROV1755
00200 Skeleton Record Switch N PROV2045
01210 Services Provided: Acute Renal Dialysis Provided by Staff SVCS PROV2055
01260 Services Provided: Alcohol and/or Drug Not Provided SVCS PROV2065
01280 Services Provided: Anesthesia Provided by Staff SVCS PROV2070
01360 Services Provided: Burn Care Unit Not Provided SVCS PROV2090
01460 Services Provided: Chiropractic Not Provided SVCS PROV2100
01530 Services Provided: ICU Cardiac (non-surgical) Provided by Staff SVCS PROV2110
01580 Services Provided: Dental Not Provided SVCS PROV2120
01670 Services Provided: Dietary Provided by Staff SVCS PROV2130
01930 Services Provided: ICU Medical/Surgical Provided by Staff SVCS PROV2185
01880 Services Provided: Inpatient Surgical Provided by Staff SVCS PROV2190
01510 Services Provided: Clinical Laboratory 1 SVCS PROV2200
02040 Services Provided: Neonatal Nursery Provided by Staff SVCS PROV2235
02100 Services Provided: Nuclear Medicine Provided by Staff SVCS PROV2245
02200 Services Provided: Obstetrics Provided by Staff SVCS PROV2265
02360 Services Provided: Occupational Therapy Provided by Staff SVCS PROV2270
01400 Services Provided: Cardiac - Thoracic Surgery Provided by Staff SVCS PROV2285
02240 Services Provided: Optometric Not Provided SVCS PROV2295
02260 Services Provided: Operating Rooms Provided by Staff SVCS PROV2300
02080 Services Provided: Organ Transplant (Not Medicare Not Provided SVCS PROV2315
02420 Services Provided: Outpatient Provided by Staff SVCS PROV2350
02480 Services Provided: Outpatient Surgery Provided by Staff SVCS PROV2355
02500 Services Provided: Pediatric Provided by Staff SVCS PROV2360
00430 Services Provided: Pharmacy Provided by Staff SVCS PROV2365
02820 Services Provided: Physical Therapy Provided by Staff SVCS PROV2370
02720 Services Provided: Postoperative Recovery Room Provided by Staff SVCS PROV2410
01230 Services Provided: Psychiatric - Adult Inpatient Provided by Staff SVCS PROV2415
01650 Services Provided: Radiology (Diagnostic) Provided by Staff SVCS PROV2440
03230 Services Provided: Radiology (Therapeutic) Provided by Staff SVCS PROV2445
02920 Services Provided: Respiratory Care Provided by Staff SVCS PROV2455
01630 Services Provided: Trauma Center (Designated) Provided by Staff SVCS PROV2475
02980 Services Provided: Social Provided by Staff SVCS PROV2485
03060 Services Provided: Speech Pathology Provided by Staff SVCS PROV2505
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Line Line Description TypeValue Field Name
00080 SSA County Code 490 PROV2695
00220 SSA State Code 10 PROV2700
00230 State Region Code LAN PROV2710
00070 Compliance: Status In Compliance PROV2715
04790 Swing Bed Switch Swing Bed service not approved PROV2795
04800 Swing Bed Size Code PROV2800
00290 General Type of Control Code Proprietary PROV2885
00410 Type of Facility Short - Term PROV2890
00300 ZIP Code 33407 PROV2905
00210 State Abbreviation FL PROV3230
00790 Current Survey Ever Swing Bed No PROV3550
00270 Termination Date / Expiration Date 1 DATE PROV4500
00260 Termination Code 1 Active PROV4770
01310 Services Provided: Audiology Not Provided SVCS PROV6160
01440 Services Provided: Chemotherapy Provided by Staff SVCS PROV6170
01560 Services Provided: CT Scanner Provided by Staff SVCS PROV6175
01720 Services Provided: Emergency Dept(Dedicated) Provided by Staff SVCS PROV6180
01760 Services Provided: Extracorporeal Shock Wave Provided under Arrangement SVCS PROV6185
01820 Services Provided: Gerontological Specialty Not Provided SVCS PROV6190
02020 Services Provided: ICU Neonatal Provided by Staff SVCS PROV6195
02520 Services Provided: ICU Pediatric Provided by Staff SVCS PROV6200
03120 Services Provided: ICU Surgical Provided by Staff SVCS PROV6205
02000 Services Provided: Magnetic Resonance Imaging Provided by Staff SVCS PROV6210
02060 Services Provided: Neurosurgical Services Provided by Staff SVCS PROV6215
02220 Services Provided: Ophthalmic Surgery Not Provided SVCS PROV6220
02280 Services Provided: Orthopedic Surgery Provided by Staff SVCS PROV6225
02540 Services Provided: PET Scan Services Not Provided SVCS PROV6230
01740 Services Provided: Psychiatric - Emergency Provided by Staff SVCS PROV6235
02740 Services Provided: Psychiatric Child/Adolescent Not Provided SVCS PROV6240
01780 Services Provided: Psychiatric - Forensic Not Provided SVCS PROV6245
01800 Services Provided: Psychiatric - Geriatric Not Provided SVCS PROV6250
02440 Services Provided: Psychiatric - Outpatient Not Provided SVCS PROV6255
02870 Services Provided: Reconstructive Surgery Not Provided SVCS PROV6260
02460 Services Provided: Rehabilitation Outpatient Provided by Staff SVCS PROV6265
01420 Services Provided: CARF Inpatient Rehabilitation C Provided by Staff SVCS PROV6270
01950 Services Provided: Transplant Center (Medicare Cer Not Provided SVCS PROV6275
03280 Services Provided: Urgent Care Center Services Not Provided SVCS PROV6280
03770 Medical Technologist Count 27 FTES PROV6290
03840 Nuclear Medicine Technician Count 2 FTES PROV6295
04310 Psychologist Count 0 FTES PROV6300
04440 Radiology Technician Count 14 FTES PROV6305
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Line Line Description TypeValue Field Name
00840 Fax Phone Number PROV9015
04230 Physician Assistants (PA) 0 PROV9020
00330 CBSA Urban Rural Indicator U SSAMSASZ
100287
GOOD SAMARITAN MEDICAL CENTER
WEST PALM BEACH, FL 33401
00320 FIPS County Code 12099 FIPCNTY
00310 FIPS State Code 12 FIPSTATE
00280 Type of Action Code 1 PR201301
00370 Affiliated Resident Program: Allopathic N PR201302
00380 Affiliated Resident Program: Dental N PR201303
00390 Affiliated Resident Program: Osteopathic N PR201304
00400 Affiliated Resident Program: Other N PR201305
01380 Services: Cardiac Catheterization Lab Code 0 PR201314
00340 Accreditation Effective Date 08/24/2007 DATE PROV0000
00350 Accreditation Expiration Date 06/07/2016 DATE PROV0005
00360 Accreditation Type Code JCAHO PROV0010
00020 Provider Category Code Hospital PROV0075
00010 Provider Category Subtype Code Short Term PROV0085
00030 Change of Ownership Count 0 PROV0095
00040 Change of Ownership Date DATE PROV0100
00060 Compliance: Plan of Correction N PROV0220
00750 Compliance: Life Safety Code N CMPL PROV0240
00770 Compliance: Scope of Service N CMPL PROV0280
00780 Compliance: Technical Personnel Waiver N CMPL PROV0285
00720 Compliance: 24 Hour Registered Nurse N CMPL PROV0290
00090 Cross Ref Provider Number CODE PROV0300
04850 Date of Validation Survey DATE PROV0450
00110 Eligibility Switch Yes PROV0455
00850 Fiscal Year Ending Date 0531 PROV0485
00100 Certification Date 07/06/2001 DATE PROV0500
00130 Intermediary Carrier Code 52280 PROV0605
00930 Medical School Affiliation No Affiliation PROV0645
00140 Medicare or Medicaid Vendor Number 010152400 CODE PROV0655
00990 Meets 1861 Definition N CMPL PROV0670
01000 Type of Non-Participating Provider PROV0690
00630 Beds-Total 333 BEDS PROV0740
00490 Beds - Total Certified 333 BEDS PROV0755
03490 Certified Registered Nurse Anesthetists (CRNA) 0 FTES PROV0760
03530 Dietitians 1 FTES PROV0820
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Line Line Description TypeValue Field Name
04460 Respiratory Therapists 10 FTES PROV0950
03670 Licensed Practical/Vocational Nurses 1 FTES PROV0955
03750 Medical Social Workers 1 FTES PROV0975
03880 Nurse Practitioners 0 FTES PROV1015
03920 Occupational Therapists 1 FTES PROV1050
03430 Other Personnel 454 FTES PROV1075
04450 Registered Pharmacists 6 FTES PROV1100
04210 Physicians 0 FTES PROV1110
04330 Physical Therapists 6 FTES PROV1125
04470 Registered Nurses 163 FTES PROV1145
04270 Physicians (Residents) 0 FTES PROV1165
04640 Speech Pathologist or Audiologist 1 FTES PROV1220
00480 Regional Override # 1 (Number Beds) No PROV1545
03380 Regional Override # 2 (Staffing) No PROV1550
01010 Regional Override # 3 (Nurse - Bed) No PROV1555
00150 Participation Date 07/06/2001 DATE PROV1565
01080 Program Participation 3 PROV1570
00250 Telephone Number 5616555511 PROV1605
00160 Prior Change of Ownership Date DATE PROV1615
00170 Intermediary Carrier Prior Code 52280 CODE PROV1620
00950 Medicare or Medicaid Participating Provider Switch Y PROV1670
00180 Provider Number 100287 CODE PROV1680
01100 Psychiatric Unit Bed Count 0 BEDS PROV1690
01110 Psychiatric Unit Effective Date DATE PROV1695
01120 Psychiatric Unit Switch No PROV1700
01130 Psychiatric Unit Termination Code PROV1705
01140 Psychiatric Unit Termination Date DATE PROV1710
00190 Region Code Atlanta PROV1725
01150 Rehabilitation Unit Bed Count 0 BEDS PROV1730
01160 Rehabilitation Unit Effective Date DATE PROV1735
01170 Rehabilitation Unit Switch No PROV1740
01180 Rehabilitation Unit Termination Code PROV1745
01190 Rehabilitation Unit Termination Date DATE PROV1750
01200 Related Provider Number CODE PROV1755
00200 Skeleton Record Switch N PROV2045
01210 Services Provided: Acute Renal Dialysis Provided under Arrangement SVCS PROV2055
01260 Services Provided: Alcohol and/or Drug Not Provided SVCS PROV2065
01280 Services Provided: Anesthesia Provided under Arrangement SVCS PROV2070
01360 Services Provided: Burn Care Unit Not Provided SVCS PROV2090
01460 Services Provided: Chiropractic Not Provided SVCS PROV2100
01530 Services Provided: ICU Cardiac (non-surgical) Provided by Staff SVCS PROV2110
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Line Line Description TypeValue Field Name
01580 Services Provided: Dental Not Provided SVCS PROV2120
01670 Services Provided: Dietary Provided by Staff SVCS PROV2130
01930 Services Provided: ICU Medical/Surgical Provided by Staff SVCS PROV2185
01880 Services Provided: Inpatient Surgical Provided by Staff SVCS PROV2190
01510 Services Provided: Clinical Laboratory 1 SVCS PROV2200
02040 Services Provided: Neonatal Nursery Provided by Staff SVCS PROV2235
02100 Services Provided: Nuclear Medicine Provided by Staff SVCS PROV2245
02200 Services Provided: Obstetrics Not Provided SVCS PROV2265
02360 Services Provided: Occupational Therapy Provided by Staff SVCS PROV2270
01400 Services Provided: Cardiac - Thoracic Surgery Not Provided SVCS PROV2285
02240 Services Provided: Optometric Not Provided SVCS PROV2295
02260 Services Provided: Operating Rooms Provided by Staff SVCS PROV2300
02080 Services Provided: Organ Transplant (Not Medicare Provided by Staff SVCS PROV2315
02420 Services Provided: Outpatient Provided by Staff SVCS PROV2350
02480 Services Provided: Outpatient Surgery Provided by Staff SVCS PROV2355
02500 Services Provided: Pediatric Not Provided SVCS PROV2360
00430 Services Provided: Pharmacy Provided by Staff SVCS PROV2365
02820 Services Provided: Physical Therapy Provided by Staff SVCS PROV2370
02720 Services Provided: Postoperative Recovery Room Provided by Staff SVCS PROV2410
01230 Services Provided: Psychiatric - Adult Inpatient Not Provided SVCS PROV2415
01650 Services Provided: Radiology (Diagnostic) Provided by Staff SVCS PROV2440
03230 Services Provided: Radiology (Therapeutic) Not Provided SVCS PROV2445
02920 Services Provided: Respiratory Care Provided by Staff SVCS PROV2455
01630 Services Provided: Trauma Center (Designated) Not Provided SVCS PROV2475
02980 Services Provided: Social Provided by Staff SVCS PROV2485
03060 Services Provided: Speech Pathology Provided by Staff SVCS PROV2505
00080 SSA County Code 490 PROV2695
00220 SSA State Code 10 PROV2700
00230 State Region Code LAN PROV2710
00070 Compliance: Status In Compliance PROV2715
04790 Swing Bed Switch Swing Bed service not approved PROV2795
04800 Swing Bed Size Code PROV2800
00290 General Type of Control Code Proprietary PROV2885
00410 Type of Facility Short - Term PROV2890
00300 ZIP Code 33401 PROV2905
00210 State Abbreviation FL PROV3230
00790 Current Survey Ever Swing Bed No PROV3550
00270 Termination Date / Expiration Date 1 DATE PROV4500
00260 Termination Code 1 Active PROV4770
01310 Services Provided: Audiology Not Provided SVCS PROV6160
01440 Services Provided: Chemotherapy Not Provided SVCS PROV6170
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Line Line Description TypeValue Field Name
01560 Services Provided: CT Scanner Not Provided SVCS PROV6175
01720 Services Provided: Emergency Dept(Dedicated) Provided by Staff and Arrangement
SVCS PROV6180
01760 Services Provided: Extracorporeal Shock Wave Not Provided SVCS PROV6185
01820 Services Provided: Gerontological Specialty Not Provided SVCS PROV6190
02020 Services Provided: ICU Neonatal Not Provided SVCS PROV6195
02520 Services Provided: ICU Pediatric Not Provided SVCS PROV6200
03120 Services Provided: ICU Surgical Not Provided SVCS PROV6205
02000 Services Provided: Magnetic Resonance Imaging Not Provided SVCS PROV6210
02060 Services Provided: Neurosurgical Services Not Provided SVCS PROV6215
02220 Services Provided: Ophthalmic Surgery Not Provided SVCS PROV6220
02280 Services Provided: Orthopedic Surgery Not Provided SVCS PROV6225
02540 Services Provided: PET Scan Services Not Provided SVCS PROV6230
01740 Services Provided: Psychiatric - Emergency Not Provided SVCS PROV6235
02740 Services Provided: Psychiatric Child/Adolescent Not Provided SVCS PROV6240
01780 Services Provided: Psychiatric - Forensic Not Provided SVCS PROV6245
01800 Services Provided: Psychiatric - Geriatric Not Provided SVCS PROV6250
02440 Services Provided: Psychiatric - Outpatient Not Provided SVCS PROV6255
02870 Services Provided: Reconstructive Surgery Not Provided SVCS PROV6260
02460 Services Provided: Rehabilitation Outpatient Not Provided SVCS PROV6265
01420 Services Provided: CARF Inpatient Rehabilitation C Not Provided SVCS PROV6270
01950 Services Provided: Transplant Center (Medicare Cer Not Provided SVCS PROV6275
03280 Services Provided: Urgent Care Center Services Not Provided SVCS PROV6280
03770 Medical Technologist Count 0 FTES PROV6290
03840 Nuclear Medicine Technician Count 0 FTES PROV6295
04310 Psychologist Count 0 FTES PROV6300
04440 Radiology Technician Count 0 FTES PROV6305
00840 Fax Phone Number PROV9015
04230 Physician Assistants (PA) 0 PROV9020
00330 CBSA Urban Rural Indicator U SSAMSASZ
100275
WELLINGTON REGIONAL MEDICAL CENTER
WELLINGTON, FL 33414
00320 FIPS County Code 12099 FIPCNTY
00310 FIPS State Code 12 FIPSTATE
00280 Type of Action Code 2 PR201301
00370 Affiliated Resident Program: Allopathic N PR201302
00380 Affiliated Resident Program: Dental N PR201303
00390 Affiliated Resident Program: Osteopathic Y PR201304
00400 Affiliated Resident Program: Other N PR201305
01380 Services: Cardiac Catheterization Lab Code 0 PR201314
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Line Line Description TypeValue Field Name
00340 Accreditation Effective Date 05/19/2011 DATE PROV0000
00350 Accreditation Expiration Date 05/18/2014 DATE PROV0005
00360 Accreditation Type Code JCAHO PROV0010
00020 Provider Category Code Hospital PROV0075
00010 Provider Category Subtype Code Short Term PROV0085
00030 Change of Ownership Count 1 PROV0095
00040 Change of Ownership Date DATE PROV0100
00060 Compliance: Plan of Correction N PROV0220
00750 Compliance: Life Safety Code N CMPL PROV0240
00770 Compliance: Scope of Service N CMPL PROV0280
00780 Compliance: Technical Personnel Waiver N CMPL PROV0285
00720 Compliance: 24 Hour Registered Nurse N CMPL PROV0290
00090 Cross Ref Provider Number CODE PROV0300
04850 Date of Validation Survey DATE PROV0450
00110 Eligibility Switch Yes PROV0455
00850 Fiscal Year Ending Date 1231 PROV0485
00100 Certification Date 11/23/1992 DATE PROV0500
00130 Intermediary Carrier Code 52280 PROV0605
00930 Medical School Affiliation Major PROV0645
00140 Medicare or Medicaid Vendor Number 010213000 CODE PROV0655
00990 Meets 1861 Definition N CMPL PROV0670
01000 Type of Non-Participating Provider PROV0690
00630 Beds-Total 233 BEDS PROV0740
00490 Beds - Total Certified 233 BEDS PROV0755
03490 Certified Registered Nurse Anesthetists (CRNA) 0 FTES PROV0760
03530 Dietitians 2 FTES PROV0820
04460 Respiratory Therapists 12 FTES PROV0950
03670 Licensed Practical/Vocational Nurses 13 FTES PROV0955
03750 Medical Social Workers 0 FTES PROV0975
03880 Nurse Practitioners 0 FTES PROV1015
03920 Occupational Therapists 0 FTES PROV1050
03430 Other Personnel 98 FTES PROV1075
04450 Registered Pharmacists 0 FTES PROV1100
04210 Physicians 1 FTES PROV1110
04330 Physical Therapists 4 FTES PROV1125
04470 Registered Nurses 155 FTES PROV1145
04270 Physicians (Residents) 8 FTES PROV1165
04640 Speech Pathologist or Audiologist 0 FTES PROV1220
00480 Regional Override # 1 (Number Beds) Yes PROV1545
03380 Regional Override # 2 (Staffing) Yes PROV1550
01010 Regional Override # 3 (Nurse - Bed) No PROV1555
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Line Line Description TypeValue Field Name
00150 Participation Date 10/09/1986 DATE PROV1565
01080 Program Participation 1 PROV1570
00250 Telephone Number 5617988500 PROV1605
00160 Prior Change of Ownership Date DATE PROV1615
00170 Intermediary Carrier Prior Code 52280 CODE PROV1620
00950 Medicare or Medicaid Participating Provider Switch Y PROV1670
00180 Provider Number 100275 CODE PROV1680
01100 Psychiatric Unit Bed Count 0 BEDS PROV1690
01110 Psychiatric Unit Effective Date DATE PROV1695
01120 Psychiatric Unit Switch No PROV1700
01130 Psychiatric Unit Termination Code PROV1705
01140 Psychiatric Unit Termination Date DATE PROV1710
00190 Region Code Atlanta PROV1725
01150 Rehabilitation Unit Bed Count 0 BEDS PROV1730
01160 Rehabilitation Unit Effective Date DATE PROV1735
01170 Rehabilitation Unit Switch No PROV1740
01180 Rehabilitation Unit Termination Code PROV1745
01190 Rehabilitation Unit Termination Date DATE PROV1750
01200 Related Provider Number CODE PROV1755
00200 Skeleton Record Switch N PROV2045
01210 Services Provided: Acute Renal Dialysis Provided under Arrangement SVCS PROV2055
01260 Services Provided: Alcohol and/or Drug Provided by Staff SVCS PROV2065
01280 Services Provided: Anesthesia Provided by Staff SVCS PROV2070
01360 Services Provided: Burn Care Unit Not Provided SVCS PROV2090
01460 Services Provided: Chiropractic Not Provided SVCS PROV2100
01530 Services Provided: ICU Cardiac (non-surgical) Provided by Staff SVCS PROV2110
01580 Services Provided: Dental Provided by Staff SVCS PROV2120
01670 Services Provided: Dietary Provided by Staff SVCS PROV2130
01930 Services Provided: ICU Medical/Surgical Provided by Staff SVCS PROV2185
01880 Services Provided: Inpatient Surgical Provided by Staff SVCS PROV2190
01510 Services Provided: Clinical Laboratory 1 SVCS PROV2200
02040 Services Provided: Neonatal Nursery Provided by Staff SVCS PROV2235
02100 Services Provided: Nuclear Medicine Provided by Staff SVCS PROV2245
02200 Services Provided: Obstetrics Provided by Staff SVCS PROV2265
02360 Services Provided: Occupational Therapy Provided under Arrangement SVCS PROV2270
01400 Services Provided: Cardiac - Thoracic Surgery Not Provided SVCS PROV2285
02240 Services Provided: Optometric Not Provided SVCS PROV2295
02260 Services Provided: Operating Rooms Provided by Staff SVCS PROV2300
02080 Services Provided: Organ Transplant (Not Medicare Provided under Arrangement SVCS PROV2315
02420 Services Provided: Outpatient Provided by Staff SVCS PROV2350
02480 Services Provided: Outpatient Surgery Provided by Staff SVCS PROV2355
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Line Line Description TypeValue Field Name
02500 Services Provided: Pediatric Provided by Staff SVCS PROV2360
00430 Services Provided: Pharmacy Provided under Arrangement SVCS PROV2365
02820 Services Provided: Physical Therapy Provided by Staff SVCS PROV2370
02720 Services Provided: Postoperative Recovery Room Provided by Staff SVCS PROV2410
01230 Services Provided: Psychiatric - Adult Inpatient Not Provided SVCS PROV2415
01650 Services Provided: Radiology (Diagnostic) Provided by Staff SVCS PROV2440
03230 Services Provided: Radiology (Therapeutic) Provided by Staff SVCS PROV2445
02920 Services Provided: Respiratory Care Provided by Staff SVCS PROV2455
01630 Services Provided: Trauma Center (Designated) Not Provided SVCS PROV2475
02980 Services Provided: Social Provided under Arrangement SVCS PROV2485
03060 Services Provided: Speech Pathology Provided under Arrangement SVCS PROV2505
00080 SSA County Code 490 PROV2695
00220 SSA State Code 10 PROV2700
00230 State Region Code LAN PROV2710
00070 Compliance: Status In Compliance PROV2715
04790 Swing Bed Switch Swing Bed service not approved PROV2795
04800 Swing Bed Size Code PROV2800
00290 General Type of Control Code Proprietary PROV2885
00410 Type of Facility Short - Term PROV2890
00300 ZIP Code 33414 PROV2905
00210 State Abbreviation FL PROV3230
00790 Current Survey Ever Swing Bed No PROV3550
00270 Termination Date / Expiration Date 1 DATE PROV4500
00260 Termination Code 1 Active PROV4770
01310 Services Provided: Audiology Not Provided SVCS PROV6160
01440 Services Provided: Chemotherapy Not Provided SVCS PROV6170
01560 Services Provided: CT Scanner Not Provided SVCS PROV6175
01720 Services Provided: Emergency Dept(Dedicated) Provided by Staff SVCS PROV6180
01760 Services Provided: Extracorporeal Shock Wave Not Provided SVCS PROV6185
01820 Services Provided: Gerontological Specialty Not Provided SVCS PROV6190
02020 Services Provided: ICU Neonatal Not Provided SVCS PROV6195
02520 Services Provided: ICU Pediatric Not Provided SVCS PROV6200
03120 Services Provided: ICU Surgical Not Provided SVCS PROV6205
02000 Services Provided: Magnetic Resonance Imaging Not Provided SVCS PROV6210
02060 Services Provided: Neurosurgical Services Not Provided SVCS PROV6215
02220 Services Provided: Ophthalmic Surgery Not Provided SVCS PROV6220
02280 Services Provided: Orthopedic Surgery Not Provided SVCS PROV6225
02540 Services Provided: PET Scan Services Not Provided SVCS PROV6230
01740 Services Provided: Psychiatric - Emergency Not Provided SVCS PROV6235
02740 Services Provided: Psychiatric Child/Adolescent Not Provided SVCS PROV6240
01780 Services Provided: Psychiatric - Forensic Not Provided SVCS PROV6245
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Line Line Description TypeValue Field Name
01800 Services Provided: Psychiatric - Geriatric Not Provided SVCS PROV6250
02440 Services Provided: Psychiatric - Outpatient Not Provided SVCS PROV6255
02870 Services Provided: Reconstructive Surgery Not Provided SVCS PROV6260
02460 Services Provided: Rehabilitation Outpatient Not Provided SVCS PROV6265
01420 Services Provided: CARF Inpatient Rehabilitation C Not Provided SVCS PROV6270
01950 Services Provided: Transplant Center (Medicare Cer Not Provided SVCS PROV6275
03280 Services Provided: Urgent Care Center Services Not Provided SVCS PROV6280
03770 Medical Technologist Count 0 FTES PROV6290
03840 Nuclear Medicine Technician Count 0 FTES PROV6295
04310 Psychologist Count 0 FTES PROV6300
04440 Radiology Technician Count 0 FTES PROV6305
00840 Fax Phone Number PROV9015
04230 Physician Assistants (PA) 0 PROV9020
00330 CBSA Urban Rural Indicator U SSAMSASZ
100269
PALMS WEST HOSPITAL
LOXAHATCHEE, FL 33470
00320 FIPS County Code 12099 FIPCNTY
00310 FIPS State Code 12 FIPSTATE
00280 Type of Action Code 8 PR201301
00370 Affiliated Resident Program: Allopathic N PR201302
00380 Affiliated Resident Program: Dental N PR201303
00390 Affiliated Resident Program: Osteopathic Y PR201304
00400 Affiliated Resident Program: Other N PR201305
01380 Services: Cardiac Catheterization Lab Code 1 PR201314
00340 Accreditation Effective Date 04/01/2011 DATE PROV0000
00350 Accreditation Expiration Date 03/31/2014 DATE PROV0005
00360 Accreditation Type Code JCAHO PROV0010
00020 Provider Category Code Hospital PROV0075
00010 Provider Category Subtype Code Short Term PROV0085
00030 Change of Ownership Count 5 PROV0095
00040 Change of Ownership Date DATE PROV0100
00060 Compliance: Plan of Correction N PROV0220
00750 Compliance: Life Safety Code N CMPL PROV0240
00770 Compliance: Scope of Service N CMPL PROV0280
00780 Compliance: Technical Personnel Waiver N CMPL PROV0285
00720 Compliance: 24 Hour Registered Nurse N CMPL PROV0290
00090 Cross Ref Provider Number CODE PROV0300
04850 Date of Validation Survey DATE PROV0450
00110 Eligibility Switch Yes PROV0455
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Line Line Description TypeValue Field Name
00850 Fiscal Year Ending Date 0831 PROV0485
00100 Certification Date 12/19/2007 DATE PROV0500
00130 Intermediary Carrier Code 00090 PROV0605
00930 Medical School Affiliation Graduate PROV0645
00140 Medicare or Medicaid Vendor Number 012026000 CODE PROV0655
00990 Meets 1861 Definition N CMPL PROV0670
01000 Type of Non-Participating Provider PROV0690
00630 Beds-Total 204 BEDS PROV0740
00490 Beds - Total Certified 204 BEDS PROV0755
03490 Certified Registered Nurse Anesthetists (CRNA) 0 FTES PROV0760
03530 Dietitians 4 FTES PROV0820
04460 Respiratory Therapists 25 FTES PROV0950
03670 Licensed Practical/Vocational Nurses 19 FTES PROV0955
03750 Medical Social Workers 0 FTES PROV0975
03880 Nurse Practitioners 0 FTES PROV1015
03920 Occupational Therapists 2 FTES PROV1050
03430 Other Personnel 295 FTES PROV1075
04450 Registered Pharmacists 0 FTES PROV1100
04210 Physicians 1 FTES PROV1110
04330 Physical Therapists 5 FTES PROV1125
04470 Registered Nurses 287 FTES PROV1145
04270 Physicians (Residents) 17 FTES PROV1165
04640 Speech Pathologist or Audiologist 2 FTES PROV1220
00480 Regional Override # 1 (Number Beds) Yes PROV1545
03380 Regional Override # 2 (Staffing) Yes PROV1550
01010 Regional Override # 3 (Nurse - Bed) Yes PROV1555
00150 Participation Date 03/06/1986 DATE PROV1565
01080 Program Participation 3 PROV1570
00250 Telephone Number 5617534245 PROV1605
00160 Prior Change of Ownership Date DATE PROV1615
00170 Intermediary Carrier Prior Code 00090 CODE PROV1620
00950 Medicare or Medicaid Participating Provider Switch Y PROV1670
00180 Provider Number 100269 CODE PROV1680
01100 Psychiatric Unit Bed Count 0 BEDS PROV1690
01110 Psychiatric Unit Effective Date DATE PROV1695
01120 Psychiatric Unit Switch No PROV1700
01130 Psychiatric Unit Termination Code PROV1705
01140 Psychiatric Unit Termination Date DATE PROV1710
00190 Region Code Atlanta PROV1725
01150 Rehabilitation Unit Bed Count 0 BEDS PROV1730
01160 Rehabilitation Unit Effective Date DATE PROV1735
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Line Line Description TypeValue Field Name
01170 Rehabilitation Unit Switch No PROV1740
01180 Rehabilitation Unit Termination Code PROV1745
01190 Rehabilitation Unit Termination Date DATE PROV1750
01200 Related Provider Number CODE PROV1755
00200 Skeleton Record Switch N PROV2045
01210 Services Provided: Acute Renal Dialysis Provided under Arrangement SVCS PROV2055
01260 Services Provided: Alcohol and/or Drug Not Provided SVCS PROV2065
01280 Services Provided: Anesthesia Provided under Arrangement SVCS PROV2070
01360 Services Provided: Burn Care Unit Not Provided SVCS PROV2090
01460 Services Provided: Chiropractic Not Provided SVCS PROV2100
01530 Services Provided: ICU Cardiac (non-surgical) Not Provided SVCS PROV2110
01580 Services Provided: Dental Not Provided SVCS PROV2120
01670 Services Provided: Dietary Provided by Staff SVCS PROV2130
01930 Services Provided: ICU Medical/Surgical Provided by Staff SVCS PROV2185
01880 Services Provided: Inpatient Surgical Provided by Staff SVCS PROV2190
01510 Services Provided: Clinical Laboratory 2 SVCS PROV2200
02040 Services Provided: Neonatal Nursery Provided by Staff SVCS PROV2235
02100 Services Provided: Nuclear Medicine Provided by Staff SVCS PROV2245
02200 Services Provided: Obstetrics Provided by Staff SVCS PROV2265
02360 Services Provided: Occupational Therapy Provided by Staff SVCS PROV2270
01400 Services Provided: Cardiac - Thoracic Surgery Not Provided SVCS PROV2285
02240 Services Provided: Optometric Not Provided SVCS PROV2295
02260 Services Provided: Operating Rooms Provided by Staff SVCS PROV2300
02080 Services Provided: Organ Transplant (Not Medicare Not Provided SVCS PROV2315
02420 Services Provided: Outpatient Provided by Staff SVCS PROV2350
02480 Services Provided: Outpatient Surgery Provided by Staff SVCS PROV2355
02500 Services Provided: Pediatric Provided by Staff SVCS PROV2360
00430 Services Provided: Pharmacy Provided under Arrangement SVCS PROV2365
02820 Services Provided: Physical Therapy Provided by Staff SVCS PROV2370
02720 Services Provided: Postoperative Recovery Room Provided by Staff SVCS PROV2410
01230 Services Provided: Psychiatric - Adult Inpatient Not Provided SVCS PROV2415
01650 Services Provided: Radiology (Diagnostic) Provided by Staff SVCS PROV2440
03230 Services Provided: Radiology (Therapeutic) Not Provided SVCS PROV2445
02920 Services Provided: Respiratory Care Provided by Staff SVCS PROV2455
01630 Services Provided: Trauma Center (Designated) Not Provided SVCS PROV2475
02980 Services Provided: Social Not Provided SVCS PROV2485
03060 Services Provided: Speech Pathology Provided by Staff SVCS PROV2505
00080 SSA County Code 490 PROV2695
00220 SSA State Code 10 PROV2700
00230 State Region Code LAN PROV2710
00070 Compliance: Status In Compliance PROV2715
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Line Line Description TypeValue Field Name
04790 Swing Bed Switch Swing Bed service not approved PROV2795
04800 Swing Bed Size Code PROV2800
00290 General Type of Control Code Proprietary PROV2885
00410 Type of Facility Short - Term PROV2890
00300 ZIP Code 33470 PROV2905
00210 State Abbreviation FL PROV3230
00790 Current Survey Ever Swing Bed No PROV3550
00270 Termination Date / Expiration Date 1 DATE PROV4500
00260 Termination Code 1 Active PROV4770
01310 Services Provided: Audiology Provided under Arrangement SVCS PROV6160
01440 Services Provided: Chemotherapy Provided by Staff SVCS PROV6170
01560 Services Provided: CT Scanner Provided by Staff SVCS PROV6175
01720 Services Provided: Emergency Dept(Dedicated) Provided by Staff SVCS PROV6180
01760 Services Provided: Extracorporeal Shock Wave Not Provided SVCS PROV6185
01820 Services Provided: Gerontological Specialty Not Provided SVCS PROV6190
02020 Services Provided: ICU Neonatal Not Provided SVCS PROV6195
02520 Services Provided: ICU Pediatric Provided by Staff SVCS PROV6200
03120 Services Provided: ICU Surgical Provided by Staff SVCS PROV6205
02000 Services Provided: Magnetic Resonance Imaging Provided by Staff SVCS PROV6210
02060 Services Provided: Neurosurgical Services Provided by Staff SVCS PROV6215
02220 Services Provided: Ophthalmic Surgery Provided by Staff SVCS PROV6220
02280 Services Provided: Orthopedic Surgery Provided by Staff SVCS PROV6225
02540 Services Provided: PET Scan Services Not Provided SVCS PROV6230
01740 Services Provided: Psychiatric - Emergency Not Provided SVCS PROV6235
02740 Services Provided: Psychiatric Child/Adolescent Not Provided SVCS PROV6240
01780 Services Provided: Psychiatric - Forensic Not Provided SVCS PROV6245
01800 Services Provided: Psychiatric - Geriatric Not Provided SVCS PROV6250
02440 Services Provided: Psychiatric - Outpatient Not Provided SVCS PROV6255
02870 Services Provided: Reconstructive Surgery Provided by Staff SVCS PROV6260
02460 Services Provided: Rehabilitation Outpatient Provided by Staff SVCS PROV6265
01420 Services Provided: CARF Inpatient Rehabilitation C Not Provided SVCS PROV6270
01950 Services Provided: Transplant Center (Medicare Cer Not Provided SVCS PROV6275
03280 Services Provided: Urgent Care Center Services Not Provided SVCS PROV6280
03770 Medical Technologist Count 0 FTES PROV6290
03840 Nuclear Medicine Technician Count 2 FTES PROV6295
04310 Psychologist Count 0 FTES PROV6300
04440 Radiology Technician Count 17 FTES PROV6305
00840 Fax Phone Number PROV9015
04230 Physician Assistants (PA) 0 PROV9020
00330 CBSA Urban Rural Indicator U SSAMSASZ
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Line Line Description TypeValue Field Name
100268
WEST BOCA MEDICAL CENTER
BOCA RATON, FL 33428
00320 FIPS County Code 12099 FIPCNTY
00310 FIPS State Code 12 FIPSTATE
00280 Type of Action Code 2 PR201301
00370 Affiliated Resident Program: Allopathic N PR201302
00380 Affiliated Resident Program: Dental N PR201303
00390 Affiliated Resident Program: Osteopathic N PR201304
00400 Affiliated Resident Program: Other N PR201305
01380 Services: Cardiac Catheterization Lab Code 0 PR201314
00340 Accreditation Effective Date 08/12/2011 DATE PROV0000
00350 Accreditation Expiration Date 08/11/2014 DATE PROV0005
00360 Accreditation Type Code JCAHO PROV0010
00020 Provider Category Code Hospital PROV0075
00010 Provider Category Subtype Code Short Term PROV0085
00030 Change of Ownership Count 2 PROV0095
00040 Change of Ownership Date 09/12/2003 DATE PROV0100
00060 Compliance: Plan of Correction N PROV0220
00750 Compliance: Life Safety Code N CMPL PROV0240
00770 Compliance: Scope of Service N CMPL PROV0280
00780 Compliance: Technical Personnel Waiver N CMPL PROV0285
00720 Compliance: 24 Hour Registered Nurse N CMPL PROV0290
00090 Cross Ref Provider Number CODE PROV0300
04850 Date of Validation Survey DATE PROV0450
00110 Eligibility Switch Yes PROV0455
00850 Fiscal Year Ending Date 1231 PROV0485
00100 Certification Date 10/28/1992 DATE PROV0500
00130 Intermediary Carrier Code 52280 PROV0605
00930 Medical School Affiliation No Affiliation PROV0645
00140 Medicare or Medicaid Vendor Number 012024300 CODE PROV0655
00990 Meets 1861 Definition N CMPL PROV0670
01000 Type of Non-Participating Provider PROV0690
00630 Beds-Total 195 BEDS PROV0740
00490 Beds - Total Certified 195 BEDS PROV0755
03490 Certified Registered Nurse Anesthetists (CRNA) 0 FTES PROV0760
03530 Dietitians 0 FTES PROV0820
04460 Respiratory Therapists 0 FTES PROV0950
03670 Licensed Practical/Vocational Nurses 10 FTES PROV0955
03750 Medical Social Workers 1 FTES PROV0975
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Line Line Description TypeValue Field Name
03880 Nurse Practitioners 0 FTES PROV1015
03920 Occupational Therapists 1 FTES PROV1050
03430 Other Personnel 179 FTES PROV1075
04450 Registered Pharmacists 11 FTES PROV1100
04210 Physicians 0 FTES PROV1110
04330 Physical Therapists 5 FTES PROV1125
04470 Registered Nurses 250 FTES PROV1145
04270 Physicians (Residents) 0 FTES PROV1165
04640 Speech Pathologist or Audiologist 1 FTES PROV1220
00480 Regional Override # 1 (Number Beds) No PROV1545
03380 Regional Override # 2 (Staffing) Yes PROV1550
01010 Regional Override # 3 (Nurse - Bed) No PROV1555
00150 Participation Date 02/06/1986 DATE PROV1565
01080 Program Participation 1 PROV1570
00250 Telephone Number 5614888000 PROV1605
00160 Prior Change of Ownership Date 06/01/2003 DATE PROV1615
00170 Intermediary Carrier Prior Code 52280 CODE PROV1620
00950 Medicare or Medicaid Participating Provider Switch Y PROV1670
00180 Provider Number 100268 CODE PROV1680
01100 Psychiatric Unit Bed Count 0 BEDS PROV1690
01110 Psychiatric Unit Effective Date DATE PROV1695
01120 Psychiatric Unit Switch No PROV1700
01130 Psychiatric Unit Termination Code PROV1705
01140 Psychiatric Unit Termination Date DATE PROV1710
00190 Region Code Atlanta PROV1725
01150 Rehabilitation Unit Bed Count 0 BEDS PROV1730
01160 Rehabilitation Unit Effective Date DATE PROV1735
01170 Rehabilitation Unit Switch No PROV1740
01180 Rehabilitation Unit Termination Code PROV1745
01190 Rehabilitation Unit Termination Date DATE PROV1750
01200 Related Provider Number CODE PROV1755
00200 Skeleton Record Switch N PROV2045
01210 Services Provided: Acute Renal Dialysis Provided under Arrangement SVCS PROV2055
01260 Services Provided: Alcohol and/or Drug Not Provided SVCS PROV2065
01280 Services Provided: Anesthesia Provided under Arrangement SVCS PROV2070
01360 Services Provided: Burn Care Unit Not Provided SVCS PROV2090
01460 Services Provided: Chiropractic Not Provided SVCS PROV2100
01530 Services Provided: ICU Cardiac (non-surgical) Provided by Staff SVCS PROV2110
01580 Services Provided: Dental Not Provided SVCS PROV2120
01670 Services Provided: Dietary Provided under Arrangement SVCS PROV2130
01930 Services Provided: ICU Medical/Surgical Provided by Staff SVCS PROV2185
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Line Line Description TypeValue Field Name
01880 Services Provided: Inpatient Surgical Provided by Staff SVCS PROV2190
01510 Services Provided: Clinical Laboratory 1 SVCS PROV2200
02040 Services Provided: Neonatal Nursery Provided by Staff SVCS PROV2235
02100 Services Provided: Nuclear Medicine Provided by Staff SVCS PROV2245
02200 Services Provided: Obstetrics Provided by Staff SVCS PROV2265
02360 Services Provided: Occupational Therapy Provided by Staff SVCS PROV2270
01400 Services Provided: Cardiac - Thoracic Surgery Not Provided SVCS PROV2285
02240 Services Provided: Optometric Not Provided SVCS PROV2295
02260 Services Provided: Operating Rooms Not Provided SVCS PROV2300
02080 Services Provided: Organ Transplant (Not Medicare Not Provided SVCS PROV2315
02420 Services Provided: Outpatient Provided by Staff SVCS PROV2350
02480 Services Provided: Outpatient Surgery Provided by Staff SVCS PROV2355
02500 Services Provided: Pediatric Provided by Staff SVCS PROV2360
00430 Services Provided: Pharmacy Provided by Staff SVCS PROV2365
02820 Services Provided: Physical Therapy Provided by Staff SVCS PROV2370
02720 Services Provided: Postoperative Recovery Room Provided by Staff SVCS PROV2410
01230 Services Provided: Psychiatric - Adult Inpatient Not Provided SVCS PROV2415
01650 Services Provided: Radiology (Diagnostic) Provided by Staff SVCS PROV2440
03230 Services Provided: Radiology (Therapeutic) Provided by Staff SVCS PROV2445
02920 Services Provided: Respiratory Care Provided under Arrangement SVCS PROV2455
01630 Services Provided: Trauma Center (Designated) Not Provided SVCS PROV2475
02980 Services Provided: Social Provided by Staff SVCS PROV2485
03060 Services Provided: Speech Pathology Provided by Staff SVCS PROV2505
00080 SSA County Code 490 PROV2695
00220 SSA State Code 10 PROV2700
00230 State Region Code LAN PROV2710
00070 Compliance: Status In Compliance PROV2715
04790 Swing Bed Switch Swing Bed service not approved PROV2795
04800 Swing Bed Size Code PROV2800
00290 General Type of Control Code Proprietary PROV2885
00410 Type of Facility Short - Term PROV2890
00300 ZIP Code 33428 PROV2905
00210 State Abbreviation FL PROV3230
00790 Current Survey Ever Swing Bed No PROV3550
00270 Termination Date / Expiration Date 1 DATE PROV4500
00260 Termination Code 1 Active PROV4770
01310 Services Provided: Audiology Not Provided SVCS PROV6160
01440 Services Provided: Chemotherapy Not Provided SVCS PROV6170
01560 Services Provided: CT Scanner Not Provided SVCS PROV6175
01720 Services Provided: Emergency Dept(Dedicated) Provided by Staff and Arrangement
SVCS PROV6180
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Line Line Description TypeValue Field Name
01760 Services Provided: Extracorporeal Shock Wave Not Provided SVCS PROV6185
01820 Services Provided: Gerontological Specialty Not Provided SVCS PROV6190
02020 Services Provided: ICU Neonatal Not Provided SVCS PROV6195
02520 Services Provided: ICU Pediatric Not Provided SVCS PROV6200
03120 Services Provided: ICU Surgical Not Provided SVCS PROV6205
02000 Services Provided: Magnetic Resonance Imaging Not Provided SVCS PROV6210
02060 Services Provided: Neurosurgical Services Not Provided SVCS PROV6215
02220 Services Provided: Ophthalmic Surgery Not Provided SVCS PROV6220
02280 Services Provided: Orthopedic Surgery Not Provided SVCS PROV6225
02540 Services Provided: PET Scan Services Not Provided SVCS PROV6230
01740 Services Provided: Psychiatric - Emergency Not Provided SVCS PROV6235
02740 Services Provided: Psychiatric Child/Adolescent Not Provided SVCS PROV6240
01780 Services Provided: Psychiatric - Forensic Not Provided SVCS PROV6245
01800 Services Provided: Psychiatric - Geriatric Not Provided SVCS PROV6250
02440 Services Provided: Psychiatric - Outpatient Not Provided SVCS PROV6255
02870 Services Provided: Reconstructive Surgery Not Provided SVCS PROV6260
02460 Services Provided: Rehabilitation Outpatient Not Provided SVCS PROV6265
01420 Services Provided: CARF Inpatient Rehabilitation C Not Provided SVCS PROV6270
01950 Services Provided: Transplant Center (Medicare Cer Not Provided SVCS PROV6275
03280 Services Provided: Urgent Care Center Services Not Provided SVCS PROV6280
03770 Medical Technologist Count 0 FTES PROV6290
03840 Nuclear Medicine Technician Count 0 FTES PROV6295
04310 Psychologist Count 0 FTES PROV6300
04440 Radiology Technician Count 0 FTES PROV6305
00840 Fax Phone Number PROV9015
04230 Physician Assistants (PA) 0 PROV9020
00330 CBSA Urban Rural Indicator U SSAMSASZ
100262
GOOD SAMARITAN HOSPITAL
WEST PALM BEACH, FL 33401
00320 FIPS County Code 12099 FIPCNTY
00310 FIPS State Code 12 FIPSTATE
00280 Type of Action Code 5 PR201301
00370 Affiliated Resident Program: Allopathic N PR201302
00380 Affiliated Resident Program: Dental N PR201303
00390 Affiliated Resident Program: Osteopathic N PR201304
00400 Affiliated Resident Program: Other N PR201305
01380 Services: Cardiac Catheterization Lab Code 0 PR201314
00340 Accreditation Effective Date 07/06/2001 DATE PROV0000
00350 Accreditation Expiration Date 07/06/2004 DATE PROV0005
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Line Line Description TypeValue Field Name
00360 Accreditation Type Code JCAHO PROV0010
00020 Provider Category Code Hospital PROV0075
00010 Provider Category Subtype Code Short Term PROV0085
00030 Change of Ownership Count 0 PROV0095
00040 Change of Ownership Date DATE PROV0100
00060 Compliance: Plan of Correction N PROV0220
00750 Compliance: Life Safety Code N CMPL PROV0240
00770 Compliance: Scope of Service N CMPL PROV0280
00780 Compliance: Technical Personnel Waiver N CMPL PROV0285
00720 Compliance: 24 Hour Registered Nurse N CMPL PROV0290
00090 Cross Ref Provider Number CODE PROV0300
04850 Date of Validation Survey 03/13/1992 DATE PROV0450
00110 Eligibility Switch Yes PROV0455
00850 Fiscal Year Ending Date 0930 PROV0485
00100 Certification Date 03/13/1992 DATE PROV0500
00130 Intermediary Carrier Code 00090 PROV0605
00930 Medical School Affiliation Limited PROV0645
00140 Medicare or Medicaid Vendor Number CODE PROV0655
00990 Meets 1861 Definition N CMPL PROV0670
01000 Type of Non-Participating Provider PROV0690
00630 Beds-Total 326 BEDS PROV0740
00490 Beds - Total Certified 326 BEDS PROV0755
03490 Certified Registered Nurse Anesthetists (CRNA) 0 FTES PROV0760
03530 Dietitians 2 FTES PROV0820
04460 Respiratory Therapists 11 FTES PROV0950
03670 Licensed Practical/Vocational Nurses 5 FTES PROV0955
03750 Medical Social Workers 4 FTES PROV0975
03880 Nurse Practitioners 0 FTES PROV1015
03920 Occupational Therapists 1 FTES PROV1050
03430 Other Personnel 534 FTES PROV1075
04450 Registered Pharmacists 12 FTES PROV1100
04210 Physicians 0 FTES PROV1110
04330 Physical Therapists 8 FTES PROV1125
04470 Registered Nurses 262 FTES PROV1145
04270 Physicians (Residents) 0 FTES PROV1165
04640 Speech Pathologist or Audiologist 1 FTES PROV1220
00480 Regional Override # 1 (Number Beds) No PROV1545
03380 Regional Override # 2 (Staffing) No PROV1550
01010 Regional Override # 3 (Nurse - Bed) No PROV1555
00150 Participation Date 03/16/1984 DATE PROV1565
01080 Program Participation 3 PROV1570
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Line Line Description TypeValue Field Name
00250 Telephone Number 4076555511 PROV1605
00160 Prior Change of Ownership Date DATE PROV1615
00170 Intermediary Carrier Prior Code CODE PROV1620
00950 Medicare or Medicaid Participating Provider Switch Y PROV1670
00180 Provider Number 100262 CODE PROV1680
01100 Psychiatric Unit Bed Count 0 BEDS PROV1690
01110 Psychiatric Unit Effective Date DATE PROV1695
01120 Psychiatric Unit Switch No PROV1700
01130 Psychiatric Unit Termination Code PROV1705
01140 Psychiatric Unit Termination Date DATE PROV1710
00190 Region Code Atlanta PROV1725
01150 Rehabilitation Unit Bed Count 0 BEDS PROV1730
01160 Rehabilitation Unit Effective Date DATE PROV1735
01170 Rehabilitation Unit Switch No PROV1740
01180 Rehabilitation Unit Termination Code PROV1745
01190 Rehabilitation Unit Termination Date DATE PROV1750
01200 Related Provider Number CODE PROV1755
00200 Skeleton Record Switch N PROV2045
01210 Services Provided: Acute Renal Dialysis Provided under Arrangement SVCS PROV2055
01260 Services Provided: Alcohol and/or Drug Not Provided SVCS PROV2065
01280 Services Provided: Anesthesia Provided under Arrangement SVCS PROV2070
01360 Services Provided: Burn Care Unit Not Provided SVCS PROV2090
01460 Services Provided: Chiropractic Not Provided SVCS PROV2100
01530 Services Provided: ICU Cardiac (non-surgical) Provided by Staff SVCS PROV2110
01580 Services Provided: Dental Not Provided SVCS PROV2120
01670 Services Provided: Dietary Provided by Staff SVCS PROV2130
01930 Services Provided: ICU Medical/Surgical Provided by Staff SVCS PROV2185
01880 Services Provided: Inpatient Surgical Provided by Staff SVCS PROV2190
01510 Services Provided: Clinical Laboratory 1 SVCS PROV2200
02040 Services Provided: Neonatal Nursery Provided by Staff SVCS PROV2235
02100 Services Provided: Nuclear Medicine Provided by Staff SVCS PROV2245
02200 Services Provided: Obstetrics Provided by Staff SVCS PROV2265
02360 Services Provided: Occupational Therapy Provided by Staff SVCS PROV2270
01400 Services Provided: Cardiac - Thoracic Surgery Not Provided SVCS PROV2285
02240 Services Provided: Optometric Not Provided SVCS PROV2295
02260 Services Provided: Operating Rooms Provided by Staff SVCS PROV2300
02080 Services Provided: Organ Transplant (Not Medicare Not Provided SVCS PROV2315
02420 Services Provided: Outpatient Provided by Staff SVCS PROV2350
02480 Services Provided: Outpatient Surgery Provided by Staff SVCS PROV2355
02500 Services Provided: Pediatric Provided by Staff SVCS PROV2360
00430 Services Provided: Pharmacy Provided by Staff SVCS PROV2365
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Line Line Description TypeValue Field Name
02820 Services Provided: Physical Therapy Provided by Staff SVCS PROV2370
02720 Services Provided: Postoperative Recovery Room Provided by Staff SVCS PROV2410
01230 Services Provided: Psychiatric - Adult Inpatient Not Provided SVCS PROV2415
01650 Services Provided: Radiology (Diagnostic) Provided by Staff SVCS PROV2440
03230 Services Provided: Radiology (Therapeutic) Provided by Staff SVCS PROV2445
02920 Services Provided: Respiratory Care Provided by Staff SVCS PROV2455
01630 Services Provided: Trauma Center (Designated) Not Provided SVCS PROV2475
02980 Services Provided: Social Provided by Staff SVCS PROV2485
03060 Services Provided: Speech Pathology Provided by Staff SVCS PROV2505
00080 SSA County Code 490 PROV2695
00220 SSA State Code 10 PROV2700
00230 State Region Code LAN PROV2710
00070 Compliance: Status In Compliance PROV2715
04790 Swing Bed Switch Swing Bed service not approved PROV2795
04800 Swing Bed Size Code PROV2800
00290 General Type of Control Code Voluntary Non-Profit - Private PROV2885
00410 Type of Facility Short - Term PROV2890
00300 ZIP Code 33401 PROV2905
00210 State Abbreviation FL PROV3230
00790 Current Survey Ever Swing Bed No PROV3550
00270 Termination Date / Expiration Date 1 07/02/2001 DATE PROV4500
00260 Termination Code 1 Voluntary - Other PROV4770
01310 Services Provided: Audiology Not Provided SVCS PROV6160
01440 Services Provided: Chemotherapy Not Provided SVCS PROV6170
01560 Services Provided: CT Scanner Not Provided SVCS PROV6175
01720 Services Provided: Emergency Dept(Dedicated) Provided by Staff and Arrangement
SVCS PROV6180
01760 Services Provided: Extracorporeal Shock Wave Not Provided SVCS PROV6185
01820 Services Provided: Gerontological Specialty Not Provided SVCS PROV6190
02020 Services Provided: ICU Neonatal Not Provided SVCS PROV6195
02520 Services Provided: ICU Pediatric Not Provided SVCS PROV6200
03120 Services Provided: ICU Surgical Not Provided SVCS PROV6205
02000 Services Provided: Magnetic Resonance Imaging Not Provided SVCS PROV6210
02060 Services Provided: Neurosurgical Services Not Provided SVCS PROV6215
02220 Services Provided: Ophthalmic Surgery Not Provided SVCS PROV6220
02280 Services Provided: Orthopedic Surgery Not Provided SVCS PROV6225
02540 Services Provided: PET Scan Services Not Provided SVCS PROV6230
01740 Services Provided: Psychiatric - Emergency Not Provided SVCS PROV6235
02740 Services Provided: Psychiatric Child/Adolescent Not Provided SVCS PROV6240
01780 Services Provided: Psychiatric - Forensic Not Provided SVCS PROV6245
01800 Services Provided: Psychiatric - Geriatric Not Provided SVCS PROV6250
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Line Line Description TypeValue Field Name
02440 Services Provided: Psychiatric - Outpatient Not Provided SVCS PROV6255
02870 Services Provided: Reconstructive Surgery Not Provided SVCS PROV6260
02460 Services Provided: Rehabilitation Outpatient Not Provided SVCS PROV6265
01420 Services Provided: CARF Inpatient Rehabilitation C Not Provided SVCS PROV6270
01950 Services Provided: Transplant Center (Medicare Cer Not Provided SVCS PROV6275
03280 Services Provided: Urgent Care Center Services Not Provided SVCS PROV6280
03770 Medical Technologist Count 0 FTES PROV6290
03840 Nuclear Medicine Technician Count 0 FTES PROV6295
04310 Psychologist Count 0 FTES PROV6300
04440 Radiology Technician Count 0 FTES PROV6305
00840 Fax Phone Number PROV9015
04230 Physician Assistants (PA) 0 PROV9020
00330 CBSA Urban Rural Indicator U SSAMSASZ
100258
DELRAY MEDICAL CENTER
DELRAY BEACH, FL 33484
00320 FIPS County Code 12099 FIPCNTY
00310 FIPS State Code 12 FIPSTATE
00280 Type of Action Code 5 PR201301
00370 Affiliated Resident Program: Allopathic N PR201302
00380 Affiliated Resident Program: Dental N PR201303
00390 Affiliated Resident Program: Osteopathic N PR201304
00400 Affiliated Resident Program: Other N PR201305
01380 Services: Cardiac Catheterization Lab Code 0 PR201314
00340 Accreditation Effective Date 07/16/2008 DATE PROV0000
00350 Accreditation Expiration Date 07/15/2011 DATE PROV0005
00360 Accreditation Type Code JCAHO PROV0010
00020 Provider Category Code Hospital PROV0075
00010 Provider Category Subtype Code Short Term PROV0085
00030 Change of Ownership Count 2 PROV0095
00040 Change of Ownership Date 09/12/2003 DATE PROV0100
00060 Compliance: Plan of Correction N PROV0220
00750 Compliance: Life Safety Code N CMPL PROV0240
00770 Compliance: Scope of Service N CMPL PROV0280
00780 Compliance: Technical Personnel Waiver N CMPL PROV0285
00720 Compliance: 24 Hour Registered Nurse N CMPL PROV0290
00090 Cross Ref Provider Number CODE PROV0300
04850 Date of Validation Survey 09/16/1999 DATE PROV0450
00110 Eligibility Switch Yes PROV0455
00850 Fiscal Year Ending Date 1231 PROV0485
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Line Line Description TypeValue Field Name
00100 Certification Date 09/16/1999 DATE PROV0500
00130 Intermediary Carrier Code 52280 PROV0605
00930 Medical School Affiliation No Affiliation PROV0645
00140 Medicare or Medicaid Vendor Number 12009000 CODE PROV0655
00990 Meets 1861 Definition N CMPL PROV0670
01000 Type of Non-Participating Provider PROV0690
00630 Beds-Total 493 BEDS PROV0740
00490 Beds - Total Certified 493 BEDS PROV0755
03490 Certified Registered Nurse Anesthetists (CRNA) 0 FTES PROV0760
03530 Dietitians 0 FTES PROV0820
04460 Respiratory Therapists 31 FTES PROV0950
03670 Licensed Practical/Vocational Nurses 23 FTES PROV0955
03750 Medical Social Workers 3 FTES PROV0975
03880 Nurse Practitioners 0 FTES PROV1015
03920 Occupational Therapists 0 FTES PROV1050
03430 Other Personnel 526 FTES PROV1075
04450 Registered Pharmacists 21 FTES PROV1100
04210 Physicians 0 FTES PROV1110
04330 Physical Therapists 2 FTES PROV1125
04470 Registered Nurses 363 FTES PROV1145
04270 Physicians (Residents) 0 FTES PROV1165
04640 Speech Pathologist or Audiologist 0 FTES PROV1220
00480 Regional Override # 1 (Number Beds) No PROV1545
03380 Regional Override # 2 (Staffing) No PROV1550
01010 Regional Override # 3 (Nurse - Bed) Yes PROV1555
00150 Participation Date 10/15/1982 DATE PROV1565
01080 Program Participation 3 PROV1570
00250 Telephone Number 5614984440 PROV1605
00160 Prior Change of Ownership Date 06/01/2003 DATE PROV1615
00170 Intermediary Carrier Prior Code 51051 CODE PROV1620
00950 Medicare or Medicaid Participating Provider Switch Y PROV1670
00180 Provider Number 100258 CODE PROV1680
01100 Psychiatric Unit Bed Count 53 BEDS PROV1690
01110 Psychiatric Unit Effective Date 01/01/2008 DATE PROV1695
01120 Psychiatric Unit Switch Yes PROV1700
01130 Psychiatric Unit Termination Code Active PROV1705
01140 Psychiatric Unit Termination Date DATE PROV1710
00190 Region Code Atlanta PROV1725
01150 Rehabilitation Unit Bed Count 90 BEDS PROV1730
01160 Rehabilitation Unit Effective Date 01/01/2008 DATE PROV1735
01170 Rehabilitation Unit Switch Yes PROV1740
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01180 Rehabilitation Unit Termination Code Active PROV1745
01190 Rehabilitation Unit Termination Date DATE PROV1750
01200 Related Provider Number CODE PROV1755
00200 Skeleton Record Switch N PROV2045
01210 Services Provided: Acute Renal Dialysis Provided under Arrangement SVCS PROV2055
01260 Services Provided: Alcohol and/or Drug Provided by Staff SVCS PROV2065
01280 Services Provided: Anesthesia Provided under Arrangement SVCS PROV2070
01360 Services Provided: Burn Care Unit Not Provided SVCS PROV2090
01460 Services Provided: Chiropractic Not Provided SVCS PROV2100
01530 Services Provided: ICU Cardiac (non-surgical) Provided by Staff SVCS PROV2110
01580 Services Provided: Dental Not Provided SVCS PROV2120
01670 Services Provided: Dietary Provided under Arrangement SVCS PROV2130
01930 Services Provided: ICU Medical/Surgical Provided by Staff SVCS PROV2185
01880 Services Provided: Inpatient Surgical Provided by Staff SVCS PROV2190
01510 Services Provided: Clinical Laboratory 3 SVCS PROV2200
02040 Services Provided: Neonatal Nursery Not Provided SVCS PROV2235
02100 Services Provided: Nuclear Medicine Provided by Staff SVCS PROV2245
02200 Services Provided: Obstetrics Not Provided SVCS PROV2265
02360 Services Provided: Occupational Therapy Provided under Arrangement SVCS PROV2270
01400 Services Provided: Cardiac - Thoracic Surgery Provided by Staff SVCS PROV2285
02240 Services Provided: Optometric Not Provided SVCS PROV2295
02260 Services Provided: Operating Rooms Provided by Staff SVCS PROV2300
02080 Services Provided: Organ Transplant (Not Medicare Not Provided SVCS PROV2315
02420 Services Provided: Outpatient Provided by Staff SVCS PROV2350
02480 Services Provided: Outpatient Surgery Provided by Staff SVCS PROV2355
02500 Services Provided: Pediatric Not Provided SVCS PROV2360
00430 Services Provided: Pharmacy Provided by Staff SVCS PROV2365
02820 Services Provided: Physical Therapy Provided by Staff SVCS PROV2370
02720 Services Provided: Postoperative Recovery Room Provided by Staff SVCS PROV2410
01230 Services Provided: Psychiatric - Adult Inpatient Provided by Staff SVCS PROV2415
01650 Services Provided: Radiology (Diagnostic) Provided by Staff SVCS PROV2440
03230 Services Provided: Radiology (Therapeutic) Not Provided SVCS PROV2445
02920 Services Provided: Respiratory Care Provided by Staff SVCS PROV2455
01630 Services Provided: Trauma Center (Designated) Provided by Staff SVCS PROV2475
02980 Services Provided: Social Provided by Staff SVCS PROV2485
03060 Services Provided: Speech Pathology Provided under Arrangement SVCS PROV2505
00080 SSA County Code 490 PROV2695
00220 SSA State Code 10 PROV2700
00230 State Region Code LAN PROV2710
00070 Compliance: Status In Compliance PROV2715
04790 Swing Bed Switch Swing Bed service not approved PROV2795
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Line Line Description TypeValue Field Name
04800 Swing Bed Size Code PROV2800
00290 General Type of Control Code Proprietary PROV2885
00410 Type of Facility Short - Term PROV2890
00300 ZIP Code 33484 PROV2905
00210 State Abbreviation FL PROV3230
00790 Current Survey Ever Swing Bed No PROV3550
00270 Termination Date / Expiration Date 1 DATE PROV4500
00260 Termination Code 1 Active PROV4770
01310 Services Provided: Audiology Not Provided SVCS PROV6160
01440 Services Provided: Chemotherapy Not Provided SVCS PROV6170
01560 Services Provided: CT Scanner Not Provided SVCS PROV6175
01720 Services Provided: Emergency Dept(Dedicated) Provided by Staff and Arrangement
SVCS PROV6180
01760 Services Provided: Extracorporeal Shock Wave Not Provided SVCS PROV6185
01820 Services Provided: Gerontological Specialty Not Provided SVCS PROV6190
02020 Services Provided: ICU Neonatal Not Provided SVCS PROV6195
02520 Services Provided: ICU Pediatric Not Provided SVCS PROV6200
03120 Services Provided: ICU Surgical Not Provided SVCS PROV6205
02000 Services Provided: Magnetic Resonance Imaging Not Provided SVCS PROV6210
02060 Services Provided: Neurosurgical Services Not Provided SVCS PROV6215
02220 Services Provided: Ophthalmic Surgery Not Provided SVCS PROV6220
02280 Services Provided: Orthopedic Surgery Not Provided SVCS PROV6225
02540 Services Provided: PET Scan Services Not Provided SVCS PROV6230
01740 Services Provided: Psychiatric - Emergency Not Provided SVCS PROV6235
02740 Services Provided: Psychiatric Child/Adolescent Not Provided SVCS PROV6240
01780 Services Provided: Psychiatric - Forensic Not Provided SVCS PROV6245
01800 Services Provided: Psychiatric - Geriatric Not Provided SVCS PROV6250
02440 Services Provided: Psychiatric - Outpatient Not Provided SVCS PROV6255
02870 Services Provided: Reconstructive Surgery Not Provided SVCS PROV6260
02460 Services Provided: Rehabilitation Outpatient Not Provided SVCS PROV6265
01420 Services Provided: CARF Inpatient Rehabilitation C Not Provided SVCS PROV6270
01950 Services Provided: Transplant Center (Medicare Cer Not Provided SVCS PROV6275
03280 Services Provided: Urgent Care Center Services Not Provided SVCS PROV6280
03770 Medical Technologist Count 0 FTES PROV6290
03840 Nuclear Medicine Technician Count 0 FTES PROV6295
04310 Psychologist Count 0 FTES PROV6300
04440 Radiology Technician Count 0 FTES PROV6305
00840 Fax Phone Number PROV9015
04230 Physician Assistants (PA) 0 PROV9020
00330 CBSA Urban Rural Indicator U SSAMSASZ
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Line Line Description TypeValue Field Name
100253
JUPITER MEDICAL CENTER
JUPITER, FL 33458
00320 FIPS County Code 12099 FIPCNTY
00310 FIPS State Code 12 FIPSTATE
00280 Type of Action Code 2 PR201301
00370 Affiliated Resident Program: Allopathic N PR201302
00380 Affiliated Resident Program: Dental N PR201303
00390 Affiliated Resident Program: Osteopathic N PR201304
00400 Affiliated Resident Program: Other N PR201305
01380 Services: Cardiac Catheterization Lab Code 2 PR201314
00340 Accreditation Effective Date 07/11/2009 DATE PROV0000
00350 Accreditation Expiration Date 07/11/2015 DATE PROV0005
00360 Accreditation Type Code JCAHO PROV0010
00020 Provider Category Code Hospital PROV0075
00010 Provider Category Subtype Code Short Term PROV0085
00030 Change of Ownership Count 0 PROV0095
00040 Change of Ownership Date DATE PROV0100
00060 Compliance: Plan of Correction N PROV0220
00750 Compliance: Life Safety Code N CMPL PROV0240
00770 Compliance: Scope of Service N CMPL PROV0280
00780 Compliance: Technical Personnel Waiver N CMPL PROV0285
00720 Compliance: 24 Hour Registered Nurse N CMPL PROV0290
00090 Cross Ref Provider Number CODE PROV0300
04850 Date of Validation Survey DATE PROV0450
00110 Eligibility Switch Yes PROV0455
00850 Fiscal Year Ending Date 0930 PROV0485
00100 Certification Date 10/01/2009 DATE PROV0500
00130 Intermediary Carrier Code 00090 PROV0605
00930 Medical School Affiliation No Affiliation PROV0645
00140 Medicare or Medicaid Vendor Number 012029400 CODE PROV0655
00990 Meets 1861 Definition N CMPL PROV0670
01000 Type of Non-Participating Provider PROV0690
00630 Beds-Total 163 BEDS PROV0740
00490 Beds - Total Certified 163 BEDS PROV0755
03490 Certified Registered Nurse Anesthetists (CRNA) 0 FTES PROV0760
03530 Dietitians 4 FTES PROV0820
04460 Respiratory Therapists 17 FTES PROV0950
03670 Licensed Practical/Vocational Nurses 14 FTES PROV0955
03750 Medical Social Workers 2 FTES PROV0975
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Line Line Description TypeValue Field Name
03880 Nurse Practitioners 1 FTES PROV1015
03920 Occupational Therapists 4 FTES PROV1050
03430 Other Personnel 582 FTES PROV1075
04450 Registered Pharmacists 10 FTES PROV1100
04210 Physicians 2 FTES PROV1110
04330 Physical Therapists 3 FTES PROV1125
04470 Registered Nurses 285 FTES PROV1145
04270 Physicians (Residents) 0 FTES PROV1165
04640 Speech Pathologist or Audiologist 2 FTES PROV1220
00480 Regional Override # 1 (Number Beds) Yes PROV1545
03380 Regional Override # 2 (Staffing) Yes PROV1550
01010 Regional Override # 3 (Nurse - Bed) Yes PROV1555
00150 Participation Date 02/14/1979 DATE PROV1565
01080 Program Participation 3 PROV1570
00250 Telephone Number 5617472234 PROV1605
00160 Prior Change of Ownership Date DATE PROV1615
00170 Intermediary Carrier Prior Code 00090 CODE PROV1620
00950 Medicare or Medicaid Participating Provider Switch Y PROV1670
00180 Provider Number 100253 CODE PROV1680
01100 Psychiatric Unit Bed Count 0 BEDS PROV1690
01110 Psychiatric Unit Effective Date DATE PROV1695
01120 Psychiatric Unit Switch No PROV1700
01130 Psychiatric Unit Termination Code PROV1705
01140 Psychiatric Unit Termination Date DATE PROV1710
00190 Region Code Atlanta PROV1725
01150 Rehabilitation Unit Bed Count 0 BEDS PROV1730
01160 Rehabilitation Unit Effective Date DATE PROV1735
01170 Rehabilitation Unit Switch No PROV1740
01180 Rehabilitation Unit Termination Code PROV1745
01190 Rehabilitation Unit Termination Date DATE PROV1750
01200 Related Provider Number CODE PROV1755
00200 Skeleton Record Switch N PROV2045
01210 Services Provided: Acute Renal Dialysis Provided under Arrangement SVCS PROV2055
01260 Services Provided: Alcohol and/or Drug Not Provided SVCS PROV2065
01280 Services Provided: Anesthesia Provided by Staff SVCS PROV2070
01360 Services Provided: Burn Care Unit Not Provided SVCS PROV2090
01460 Services Provided: Chiropractic Not Provided SVCS PROV2100
01530 Services Provided: ICU Cardiac (non-surgical) Not Provided SVCS PROV2110
01580 Services Provided: Dental Not Provided SVCS PROV2120
01670 Services Provided: Dietary Provided by Staff SVCS PROV2130
01930 Services Provided: ICU Medical/Surgical Provided by Staff SVCS PROV2185
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Line Line Description TypeValue Field Name
01880 Services Provided: Inpatient Surgical Provided under Arrangement SVCS PROV2190
01510 Services Provided: Clinical Laboratory 1 SVCS PROV2200
02040 Services Provided: Neonatal Nursery Not Provided SVCS PROV2235
02100 Services Provided: Nuclear Medicine Provided by Staff SVCS PROV2245
02200 Services Provided: Obstetrics Provided by Staff SVCS PROV2265
02360 Services Provided: Occupational Therapy Provided by Staff SVCS PROV2270
01400 Services Provided: Cardiac - Thoracic Surgery Not Provided SVCS PROV2285
02240 Services Provided: Optometric Not Provided SVCS PROV2295
02260 Services Provided: Operating Rooms Provided by Staff SVCS PROV2300
02080 Services Provided: Organ Transplant (Not Medicare Not Provided SVCS PROV2315
02420 Services Provided: Outpatient Provided by Staff SVCS PROV2350
02480 Services Provided: Outpatient Surgery Provided by Staff SVCS PROV2355
02500 Services Provided: Pediatric Provided by Staff and Arrangement
SVCS PROV2360
00430 Services Provided: Pharmacy Provided by Staff SVCS PROV2365
02820 Services Provided: Physical Therapy Provided by Staff SVCS PROV2370
02720 Services Provided: Postoperative Recovery Room Provided by Staff SVCS PROV2410
01230 Services Provided: Psychiatric - Adult Inpatient Not Provided SVCS PROV2415
01650 Services Provided: Radiology (Diagnostic) Provided by Staff SVCS PROV2440
03230 Services Provided: Radiology (Therapeutic) Provided by Staff SVCS PROV2445
02920 Services Provided: Respiratory Care Provided by Staff SVCS PROV2455
01630 Services Provided: Trauma Center (Designated) Provided under Arrangement SVCS PROV2475
02980 Services Provided: Social Provided by Staff SVCS PROV2485
03060 Services Provided: Speech Pathology Provided by Staff SVCS PROV2505
00080 SSA County Code 490 PROV2695
00220 SSA State Code 10 PROV2700
00230 State Region Code LAN PROV2710
00070 Compliance: Status In Compliance PROV2715
04790 Swing Bed Switch Swing Bed service not approved PROV2795
04800 Swing Bed Size Code PROV2800
00290 General Type of Control Code Voluntary Non-Profit - Private PROV2885
00410 Type of Facility Short - Term PROV2890
00300 ZIP Code 33458 PROV2905
00210 State Abbreviation FL PROV3230
00790 Current Survey Ever Swing Bed No PROV3550
00270 Termination Date / Expiration Date 1 DATE PROV4500
00260 Termination Code 1 Active PROV4770
01310 Services Provided: Audiology Not Provided SVCS PROV6160
01440 Services Provided: Chemotherapy Provided by Staff SVCS PROV6170
01560 Services Provided: CT Scanner Provided by Staff SVCS PROV6175
01720 Services Provided: Emergency Dept(Dedicated) Provided by Staff SVCS PROV6180
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Line Line Description TypeValue Field Name
01760 Services Provided: Extracorporeal Shock Wave Not Provided SVCS PROV6185
01820 Services Provided: Gerontological Specialty Not Provided SVCS PROV6190
02020 Services Provided: ICU Neonatal Not Provided SVCS PROV6195
02520 Services Provided: ICU Pediatric Not Provided SVCS PROV6200
03120 Services Provided: ICU Surgical Not Provided SVCS PROV6205
02000 Services Provided: Magnetic Resonance Imaging Provided by Staff SVCS PROV6210
02060 Services Provided: Neurosurgical Services Provided by Staff and Arrangement
SVCS PROV6215
02220 Services Provided: Ophthalmic Surgery Not Provided SVCS PROV6220
02280 Services Provided: Orthopedic Surgery Provided by Staff SVCS PROV6225
02540 Services Provided: PET Scan Services Provided by Staff SVCS PROV6230
01740 Services Provided: Psychiatric - Emergency Not Provided SVCS PROV6235
02740 Services Provided: Psychiatric Child/Adolescent Not Provided SVCS PROV6240
01780 Services Provided: Psychiatric - Forensic Not Provided SVCS PROV6245
01800 Services Provided: Psychiatric - Geriatric Not Provided SVCS PROV6250
02440 Services Provided: Psychiatric - Outpatient Not Provided SVCS PROV6255
02870 Services Provided: Reconstructive Surgery Provided by Staff SVCS PROV6260
02460 Services Provided: Rehabilitation Outpatient Provided by Staff SVCS PROV6265
01420 Services Provided: CARF Inpatient Rehabilitation C Not Provided SVCS PROV6270
01950 Services Provided: Transplant Center (Medicare Cer Not Provided SVCS PROV6275
03280 Services Provided: Urgent Care Center Services Not Provided SVCS PROV6280
03770 Medical Technologist Count 21 FTES PROV6290
03840 Nuclear Medicine Technician Count 3 FTES PROV6295
04310 Psychologist Count 0 FTES PROV6300
04440 Radiology Technician Count 8 FTES PROV6305
00840 Fax Phone Number PROV9015
04230 Physician Assistants (PA) 0 PROV9020
00330 CBSA Urban Rural Indicator U SSAMSASZ
100234
WEST PALM HOSPITAL
WEST PALM BEACH, FL 33407
00320 FIPS County Code 12099 FIPCNTY
00310 FIPS State Code 12 FIPSTATE
00280 Type of Action Code 5 PR201301
00370 Affiliated Resident Program: Allopathic N PR201302
00380 Affiliated Resident Program: Dental N PR201303
00390 Affiliated Resident Program: Osteopathic Y PR201304
00400 Affiliated Resident Program: Other N PR201305
01380 Services: Cardiac Catheterization Lab Code 0 PR201314
00340 Accreditation Effective Date 10/05/2007 DATE PROV0000
00350 Accreditation Expiration Date 10/04/2010 DATE PROV0005
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Line Line Description TypeValue Field Name
00360 Accreditation Type Code JCAHO PROV0010
00020 Provider Category Code Hospital PROV0075
00010 Provider Category Subtype Code Short Term PROV0085
00030 Change of Ownership Count 3 PROV0095
00040 Change of Ownership Date DATE PROV0100
00060 Compliance: Plan of Correction Y PROV0220
00750 Compliance: Life Safety Code N CMPL PROV0240
00770 Compliance: Scope of Service N CMPL PROV0280
00780 Compliance: Technical Personnel Waiver N CMPL PROV0285
00720 Compliance: 24 Hour Registered Nurse N CMPL PROV0290
00090 Cross Ref Provider Number CODE PROV0300
04850 Date of Validation Survey 07/25/2001 DATE PROV0450
00110 Eligibility Switch Yes PROV0455
00850 Fiscal Year Ending Date 0630 PROV0485
00100 Certification Date 07/25/2001 DATE PROV0500
00130 Intermediary Carrier Code 52280 PROV0605
00930 Medical School Affiliation Limited PROV0645
00140 Medicare or Medicaid Vendor Number 012030800 CODE PROV0655
00990 Meets 1861 Definition N CMPL PROV0670
01000 Type of Non-Participating Provider PROV0690
00630 Beds-Total 245 BEDS PROV0740
00490 Beds - Total Certified 245 BEDS PROV0755
03490 Certified Registered Nurse Anesthetists (CRNA) 0 FTES PROV0760
03530 Dietitians 25 FTES PROV0820
04460 Respiratory Therapists 15 FTES PROV0950
03670 Licensed Practical/Vocational Nurses 5 FTES PROV0955
03750 Medical Social Workers 81 FTES PROV0975
03880 Nurse Practitioners 0 FTES PROV1015
03920 Occupational Therapists 14 FTES PROV1050
03430 Other Personnel 386 FTES PROV1075
04450 Registered Pharmacists 6 FTES PROV1100
04210 Physicians 0 FTES PROV1110
04330 Physical Therapists 3 FTES PROV1125
04470 Registered Nurses 15 FTES PROV1145
04270 Physicians (Residents) 14 FTES PROV1165
04640 Speech Pathologist or Audiologist 0 FTES PROV1220
00480 Regional Override # 1 (Number Beds) No PROV1545
03380 Regional Override # 2 (Staffing) No PROV1550
01010 Regional Override # 3 (Nurse - Bed) Yes PROV1555
00150 Participation Date 09/22/1975 DATE PROV1565
01080 Program Participation 3 PROV1570
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Line Line Description TypeValue Field Name
00250 Telephone Number 5618446141 PROV1605
00160 Prior Change of Ownership Date 06/29/1997 DATE PROV1615
00170 Intermediary Carrier Prior Code CODE PROV1620
00950 Medicare or Medicaid Participating Provider Switch Y PROV1670
00180 Provider Number 100234 CODE PROV1680
01100 Psychiatric Unit Bed Count 61 BEDS PROV1690
01110 Psychiatric Unit Effective Date 07/01/1998 DATE PROV1695
01120 Psychiatric Unit Switch Yes PROV1700
01130 Psychiatric Unit Termination Code Active PROV1705
01140 Psychiatric Unit Termination Date DATE PROV1710
00190 Region Code Atlanta PROV1725
01150 Rehabilitation Unit Bed Count 0 BEDS PROV1730
01160 Rehabilitation Unit Effective Date DATE PROV1735
01170 Rehabilitation Unit Switch No PROV1740
01180 Rehabilitation Unit Termination Code PROV1745
01190 Rehabilitation Unit Termination Date DATE PROV1750
01200 Related Provider Number CODE PROV1755
00200 Skeleton Record Switch N PROV2045
01210 Services Provided: Acute Renal Dialysis Provided by Staff SVCS PROV2055
01260 Services Provided: Alcohol and/or Drug Provided by Staff SVCS PROV2065
01280 Services Provided: Anesthesia Provided by Staff SVCS PROV2070
01360 Services Provided: Burn Care Unit Not Provided SVCS PROV2090
01460 Services Provided: Chiropractic Not Provided SVCS PROV2100
01530 Services Provided: ICU Cardiac (non-surgical) Provided by Staff SVCS PROV2110
01580 Services Provided: Dental Not Provided SVCS PROV2120
01670 Services Provided: Dietary Provided by Staff SVCS PROV2130
01930 Services Provided: ICU Medical/Surgical Provided by Staff SVCS PROV2185
01880 Services Provided: Inpatient Surgical Provided by Staff SVCS PROV2190
01510 Services Provided: Clinical Laboratory 1 SVCS PROV2200
02040 Services Provided: Neonatal Nursery Provided by Staff SVCS PROV2235
02100 Services Provided: Nuclear Medicine Provided by Staff SVCS PROV2245
02200 Services Provided: Obstetrics Provided by Staff SVCS PROV2265
02360 Services Provided: Occupational Therapy Provided by Staff SVCS PROV2270
01400 Services Provided: Cardiac - Thoracic Surgery Not Provided SVCS PROV2285
02240 Services Provided: Optometric Provided by Staff SVCS PROV2295
02260 Services Provided: Operating Rooms Provided by Staff SVCS PROV2300
02080 Services Provided: Organ Transplant (Not Medicare Not Provided SVCS PROV2315
02420 Services Provided: Outpatient Provided by Staff SVCS PROV2350
02480 Services Provided: Outpatient Surgery Provided by Staff SVCS PROV2355
02500 Services Provided: Pediatric Provided by Staff SVCS PROV2360
00430 Services Provided: Pharmacy Provided by Staff SVCS PROV2365
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Line Line Description TypeValue Field Name
02820 Services Provided: Physical Therapy Provided by Staff SVCS PROV2370
02720 Services Provided: Postoperative Recovery Room Provided by Staff SVCS PROV2410
01230 Services Provided: Psychiatric - Adult Inpatient Provided by Staff SVCS PROV2415
01650 Services Provided: Radiology (Diagnostic) Provided by Staff SVCS PROV2440
03230 Services Provided: Radiology (Therapeutic) Provided by Staff SVCS PROV2445
02920 Services Provided: Respiratory Care Provided by Staff SVCS PROV2455
01630 Services Provided: Trauma Center (Designated) Not Provided SVCS PROV2475
02980 Services Provided: Social Provided by Staff SVCS PROV2485
03060 Services Provided: Speech Pathology Provided by Staff SVCS PROV2505
00080 SSA County Code 490 PROV2695
00220 SSA State Code 10 PROV2700
00230 State Region Code LAN PROV2710
00070 Compliance: Status In Compliance PROV2715
04790 Swing Bed Switch Swing Bed service not approved PROV2795
04800 Swing Bed Size Code PROV2800
00290 General Type of Control Code Proprietary PROV2885
00410 Type of Facility Short - Term PROV2890
00300 ZIP Code 33407 PROV2905
00210 State Abbreviation FL PROV3230
00790 Current Survey Ever Swing Bed No PROV3550
00270 Termination Date / Expiration Date 1 DATE PROV4500
00260 Termination Code 1 Active PROV4770
01310 Services Provided: Audiology Not Provided SVCS PROV6160
01440 Services Provided: Chemotherapy Not Provided SVCS PROV6170
01560 Services Provided: CT Scanner Not Provided SVCS PROV6175
01720 Services Provided: Emergency Dept(Dedicated) Provided by Staff SVCS PROV6180
01760 Services Provided: Extracorporeal Shock Wave Not Provided SVCS PROV6185
01820 Services Provided: Gerontological Specialty Not Provided SVCS PROV6190
02020 Services Provided: ICU Neonatal Not Provided SVCS PROV6195
02520 Services Provided: ICU Pediatric Not Provided SVCS PROV6200
03120 Services Provided: ICU Surgical Not Provided SVCS PROV6205
02000 Services Provided: Magnetic Resonance Imaging Not Provided SVCS PROV6210
02060 Services Provided: Neurosurgical Services Not Provided SVCS PROV6215
02220 Services Provided: Ophthalmic Surgery Not Provided SVCS PROV6220
02280 Services Provided: Orthopedic Surgery Not Provided SVCS PROV6225
02540 Services Provided: PET Scan Services Not Provided SVCS PROV6230
01740 Services Provided: Psychiatric - Emergency Not Provided SVCS PROV6235
02740 Services Provided: Psychiatric Child/Adolescent Not Provided SVCS PROV6240
01780 Services Provided: Psychiatric - Forensic Not Provided SVCS PROV6245
01800 Services Provided: Psychiatric - Geriatric Not Provided SVCS PROV6250
02440 Services Provided: Psychiatric - Outpatient Not Provided SVCS PROV6255
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Line Line Description TypeValue Field Name
02870 Services Provided: Reconstructive Surgery Not Provided SVCS PROV6260
02460 Services Provided: Rehabilitation Outpatient Not Provided SVCS PROV6265
01420 Services Provided: CARF Inpatient Rehabilitation C Not Provided SVCS PROV6270
01950 Services Provided: Transplant Center (Medicare Cer Not Provided SVCS PROV6275
03280 Services Provided: Urgent Care Center Services Not Provided SVCS PROV6280
03770 Medical Technologist Count 0 FTES PROV6290
03840 Nuclear Medicine Technician Count 0 FTES PROV6295
04310 Psychologist Count 0 FTES PROV6300
04440 Radiology Technician Count 0 FTES PROV6305
00840 Fax Phone Number PROV9015
04230 Physician Assistants (PA) 0 PROV9020
00330 CBSA Urban Rural Indicator U SSAMSASZ
100207
PALM BEACH REGIONAL HOSPITAL
LAKE WORTH, FL 33460
00320 FIPS County Code 12099 FIPCNTY
00310 FIPS State Code 12 FIPSTATE
00280 Type of Action Code 2 PR201301
00370 Affiliated Resident Program: Allopathic N PR201302
00380 Affiliated Resident Program: Dental N PR201303
00390 Affiliated Resident Program: Osteopathic N PR201304
00400 Affiliated Resident Program: Other N PR201305
01380 Services: Cardiac Catheterization Lab Code 0 PR201314
00340 Accreditation Effective Date 08/15/1990 DATE PROV0000
00350 Accreditation Expiration Date 08/15/1993 DATE PROV0005
00360 Accreditation Type Code JCAHO PROV0010
00020 Provider Category Code Hospital PROV0075
00010 Provider Category Subtype Code Short Term PROV0085
00030 Change of Ownership Count 2 PROV0095
00040 Change of Ownership Date DATE PROV0100
00060 Compliance: Plan of Correction N PROV0220
00750 Compliance: Life Safety Code N CMPL PROV0240
00770 Compliance: Scope of Service N CMPL PROV0280
00780 Compliance: Technical Personnel Waiver N CMPL PROV0285
00720 Compliance: 24 Hour Registered Nurse N CMPL PROV0290
00090 Cross Ref Provider Number CODE PROV0300
04850 Date of Validation Survey DATE PROV0450
00110 Eligibility Switch No PROV0455
00850 Fiscal Year Ending Date 0331 PROV0485
00100 Certification Date 12/30/1992 DATE PROV0500
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Line Line Description TypeValue Field Name
00130 Intermediary Carrier Code 00090 PROV0605
00930 Medical School Affiliation No Affiliation PROV0645
00140 Medicare or Medicaid Vendor Number 105957 CODE PROV0655
00990 Meets 1861 Definition N CMPL PROV0670
01000 Type of Non-Participating Provider PROV0690
00630 Beds-Total 200 BEDS PROV0740
00490 Beds - Total Certified 200 BEDS PROV0755
03490 Certified Registered Nurse Anesthetists (CRNA) 0 FTES PROV0760
03530 Dietitians 1 FTES PROV0820
04460 Respiratory Therapists 12 FTES PROV0950
03670 Licensed Practical/Vocational Nurses 51 FTES PROV0955
03750 Medical Social Workers 2 FTES PROV0975
03880 Nurse Practitioners 0 FTES PROV1015
03920 Occupational Therapists 0 FTES PROV1050
03430 Other Personnel 245 FTES PROV1075
04450 Registered Pharmacists 4 FTES PROV1100
04210 Physicians 0 FTES PROV1110
04330 Physical Therapists 0 FTES PROV1125
04470 Registered Nurses 76 FTES PROV1145
04270 Physicians (Residents) 0 FTES PROV1165
04640 Speech Pathologist or Audiologist 0 FTES PROV1220
00480 Regional Override # 1 (Number Beds) No PROV1545
03380 Regional Override # 2 (Staffing) No PROV1550
01010 Regional Override # 3 (Nurse - Bed) No PROV1555
00150 Participation Date 01/22/1973 DATE PROV1565
01080 Program Participation 3 PROV1570
00250 Telephone Number 4079677800 PROV1605
00160 Prior Change of Ownership Date 06/30/1980 DATE PROV1615
00170 Intermediary Carrier Prior Code CODE PROV1620
00950 Medicare or Medicaid Participating Provider Switch Y PROV1670
00180 Provider Number 100207 CODE PROV1680
01100 Psychiatric Unit Bed Count 0 BEDS PROV1690
01110 Psychiatric Unit Effective Date DATE PROV1695
01120 Psychiatric Unit Switch No PROV1700
01130 Psychiatric Unit Termination Code PROV1705
01140 Psychiatric Unit Termination Date DATE PROV1710
00190 Region Code Atlanta PROV1725
01150 Rehabilitation Unit Bed Count 0 BEDS PROV1730
01160 Rehabilitation Unit Effective Date DATE PROV1735
01170 Rehabilitation Unit Switch No PROV1740
01180 Rehabilitation Unit Termination Code PROV1745
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01190 Rehabilitation Unit Termination Date DATE PROV1750
01200 Related Provider Number CODE PROV1755
00200 Skeleton Record Switch N PROV2045
01210 Services Provided: Acute Renal Dialysis Provided under Arrangement SVCS PROV2055
01260 Services Provided: Alcohol and/or Drug Not Provided SVCS PROV2065
01280 Services Provided: Anesthesia Provided under Arrangement SVCS PROV2070
01360 Services Provided: Burn Care Unit Not Provided SVCS PROV2090
01460 Services Provided: Chiropractic Not Provided SVCS PROV2100
01530 Services Provided: ICU Cardiac (non-surgical) Provided by Staff SVCS PROV2110
01580 Services Provided: Dental Not Provided SVCS PROV2120
01670 Services Provided: Dietary Provided by Staff SVCS PROV2130
01930 Services Provided: ICU Medical/Surgical Provided by Staff SVCS PROV2185
01880 Services Provided: Inpatient Surgical Provided by Staff SVCS PROV2190
01510 Services Provided: Clinical Laboratory 1 SVCS PROV2200
02040 Services Provided: Neonatal Nursery Not Provided SVCS PROV2235
02100 Services Provided: Nuclear Medicine Provided by Staff SVCS PROV2245
02200 Services Provided: Obstetrics Not Provided SVCS PROV2265
02360 Services Provided: Occupational Therapy Provided under Arrangement SVCS PROV2270
01400 Services Provided: Cardiac - Thoracic Surgery Not Provided SVCS PROV2285
02240 Services Provided: Optometric Not Provided SVCS PROV2295
02260 Services Provided: Operating Rooms Provided by Staff SVCS PROV2300
02080 Services Provided: Organ Transplant (Not Medicare Not Provided SVCS PROV2315
02420 Services Provided: Outpatient Provided by Staff SVCS PROV2350
02480 Services Provided: Outpatient Surgery Provided by Staff SVCS PROV2355
02500 Services Provided: Pediatric Not Provided SVCS PROV2360
00430 Services Provided: Pharmacy Provided by Staff SVCS PROV2365
02820 Services Provided: Physical Therapy Provided under Arrangement SVCS PROV2370
02720 Services Provided: Postoperative Recovery Room Provided by Staff SVCS PROV2410
01230 Services Provided: Psychiatric - Adult Inpatient Not Provided SVCS PROV2415
01650 Services Provided: Radiology (Diagnostic) Provided by Staff SVCS PROV2440
03230 Services Provided: Radiology (Therapeutic) Not Provided SVCS PROV2445
02920 Services Provided: Respiratory Care Provided by Staff SVCS PROV2455
01630 Services Provided: Trauma Center (Designated) Not Provided SVCS PROV2475
02980 Services Provided: Social Provided by Staff SVCS PROV2485
03060 Services Provided: Speech Pathology Provided under Arrangement SVCS PROV2505
00080 SSA County Code 490 PROV2695
00220 SSA State Code 10 PROV2700
00230 State Region Code LAN PROV2710
00070 Compliance: Status In Compliance PROV2715
04790 Swing Bed Switch Swing Bed service not approved PROV2795
04800 Swing Bed Size Code PROV2800
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Line Line Description TypeValue Field Name
00290 General Type of Control Code Proprietary PROV2885
00410 Type of Facility Short - Term PROV2890
00300 ZIP Code 33460 PROV2905
00210 State Abbreviation FL PROV3230
00790 Current Survey Ever Swing Bed No PROV3550
00270 Termination Date / Expiration Date 1 11/07/1997 DATE PROV4500
00260 Termination Code 1 Voluntary - Reimburse PROV4770
01310 Services Provided: Audiology Not Provided SVCS PROV6160
01440 Services Provided: Chemotherapy Not Provided SVCS PROV6170
01560 Services Provided: CT Scanner Not Provided SVCS PROV6175
01720 Services Provided: Emergency Dept(Dedicated) Provided by Staff SVCS PROV6180
01760 Services Provided: Extracorporeal Shock Wave Not Provided SVCS PROV6185
01820 Services Provided: Gerontological Specialty Not Provided SVCS PROV6190
02020 Services Provided: ICU Neonatal Not Provided SVCS PROV6195
02520 Services Provided: ICU Pediatric Not Provided SVCS PROV6200
03120 Services Provided: ICU Surgical Not Provided SVCS PROV6205
02000 Services Provided: Magnetic Resonance Imaging Not Provided SVCS PROV6210
02060 Services Provided: Neurosurgical Services Not Provided SVCS PROV6215
02220 Services Provided: Ophthalmic Surgery Not Provided SVCS PROV6220
02280 Services Provided: Orthopedic Surgery Not Provided SVCS PROV6225
02540 Services Provided: PET Scan Services Not Provided SVCS PROV6230
01740 Services Provided: Psychiatric - Emergency Not Provided SVCS PROV6235
02740 Services Provided: Psychiatric Child/Adolescent Not Provided SVCS PROV6240
01780 Services Provided: Psychiatric - Forensic Not Provided SVCS PROV6245
01800 Services Provided: Psychiatric - Geriatric Not Provided SVCS PROV6250
02440 Services Provided: Psychiatric - Outpatient Not Provided SVCS PROV6255
02870 Services Provided: Reconstructive Surgery Not Provided SVCS PROV6260
02460 Services Provided: Rehabilitation Outpatient Not Provided SVCS PROV6265
01420 Services Provided: CARF Inpatient Rehabilitation C Not Provided SVCS PROV6270
01950 Services Provided: Transplant Center (Medicare Cer Not Provided SVCS PROV6275
03280 Services Provided: Urgent Care Center Services Not Provided SVCS PROV6280
03770 Medical Technologist Count 0 FTES PROV6290
03840 Nuclear Medicine Technician Count 0 FTES PROV6295
04310 Psychologist Count 0 FTES PROV6300
04440 Radiology Technician Count 0 FTES PROV6305
00840 Fax Phone Number PROV9015
04230 Physician Assistants (PA) 0 PROV9020
00330 CBSA Urban Rural Indicator U SSAMSASZ
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Line Line Description TypeValue Field Name
100176
PALM BEACH GARDENS MEDICAL CENTER
PALM BEACH GARDENS, FL 33410
00320 FIPS County Code 12099 FIPCNTY
00310 FIPS State Code 12 FIPSTATE
00280 Type of Action Code 2 PR201301
00370 Affiliated Resident Program: Allopathic N PR201302
00380 Affiliated Resident Program: Dental N PR201303
00390 Affiliated Resident Program: Osteopathic N PR201304
00400 Affiliated Resident Program: Other N PR201305
01380 Services: Cardiac Catheterization Lab Code 1 PR201314
00340 Accreditation Effective Date 06/22/2012 DATE PROV0000
00350 Accreditation Expiration Date 06/22/2015 DATE PROV0005
00360 Accreditation Type Code JCAHO PROV0010
00020 Provider Category Code Hospital PROV0075
00010 Provider Category Subtype Code Short Term PROV0085
00030 Change of Ownership Count 0 PROV0095
00040 Change of Ownership Date DATE PROV0100
00060 Compliance: Plan of Correction N PROV0220
00750 Compliance: Life Safety Code N CMPL PROV0240
00770 Compliance: Scope of Service N CMPL PROV0280
00780 Compliance: Technical Personnel Waiver N CMPL PROV0285
00720 Compliance: 24 Hour Registered Nurse N CMPL PROV0290
00090 Cross Ref Provider Number CODE PROV0300
04850 Date of Validation Survey DATE PROV0450
00110 Eligibility Switch Yes PROV0455
00850 Fiscal Year Ending Date 1231 PROV0485
00100 Certification Date 10/22/2009 DATE PROV0500
00130 Intermediary Carrier Code 52280 PROV0605
00930 Medical School Affiliation No Affiliation PROV0645
00140 Medicare or Medicaid Vendor Number 010210500 CODE PROV0655
00990 Meets 1861 Definition N CMPL PROV0670
01000 Type of Non-Participating Provider PROV0690
00630 Beds-Total 199 BEDS PROV0740
00490 Beds - Total Certified 199 BEDS PROV0755
03490 Certified Registered Nurse Anesthetists (CRNA) 0 FTES PROV0760
03530 Dietitians 0 FTES PROV0820
04460 Respiratory Therapists 17 FTES PROV0950
03670 Licensed Practical/Vocational Nurses 0 FTES PROV0955
03750 Medical Social Workers 1 FTES PROV0975
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Line Line Description TypeValue Field Name
03880 Nurse Practitioners 0 FTES PROV1015
03920 Occupational Therapists 2 FTES PROV1050
03430 Other Personnel 289 FTES PROV1075
04450 Registered Pharmacists 11 FTES PROV1100
04210 Physicians 0 FTES PROV1110
04330 Physical Therapists 6 FTES PROV1125
04470 Registered Nurses 249 FTES PROV1145
04270 Physicians (Residents) 0 FTES PROV1165
04640 Speech Pathologist or Audiologist 2 FTES PROV1220
00480 Regional Override # 1 (Number Beds) No PROV1545
03380 Regional Override # 2 (Staffing) No PROV1550
01010 Regional Override # 3 (Nurse - Bed) No PROV1555
00150 Participation Date 12/14/1970 DATE PROV1565
01080 Program Participation 1 PROV1570
00250 Telephone Number 5616221411 PROV1605
00160 Prior Change of Ownership Date DATE PROV1615
00170 Intermediary Carrier Prior Code 52280 CODE PROV1620
00950 Medicare or Medicaid Participating Provider Switch Y PROV1670
00180 Provider Number 100176 CODE PROV1680
01100 Psychiatric Unit Bed Count 0 BEDS PROV1690
01110 Psychiatric Unit Effective Date DATE PROV1695
01120 Psychiatric Unit Switch No PROV1700
01130 Psychiatric Unit Termination Code PROV1705
01140 Psychiatric Unit Termination Date DATE PROV1710
00190 Region Code Atlanta PROV1725
01150 Rehabilitation Unit Bed Count 0 BEDS PROV1730
01160 Rehabilitation Unit Effective Date DATE PROV1735
01170 Rehabilitation Unit Switch No PROV1740
01180 Rehabilitation Unit Termination Code PROV1745
01190 Rehabilitation Unit Termination Date DATE PROV1750
01200 Related Provider Number CODE PROV1755
00200 Skeleton Record Switch N PROV2045
01210 Services Provided: Acute Renal Dialysis Provided under Arrangement SVCS PROV2055
01260 Services Provided: Alcohol and/or Drug Not Provided SVCS PROV2065
01280 Services Provided: Anesthesia Provided under Arrangement SVCS PROV2070
01360 Services Provided: Burn Care Unit Not Provided SVCS PROV2090
01460 Services Provided: Chiropractic Not Provided SVCS PROV2100
01530 Services Provided: ICU Cardiac (non-surgical) Provided by Staff SVCS PROV2110
01580 Services Provided: Dental Not Provided SVCS PROV2120
01670 Services Provided: Dietary Provided under Arrangement SVCS PROV2130
01930 Services Provided: ICU Medical/Surgical Provided by Staff SVCS PROV2185
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Line Line Description TypeValue Field Name
01880 Services Provided: Inpatient Surgical Provided by Staff SVCS PROV2190
01510 Services Provided: Clinical Laboratory 3 SVCS PROV2200
02040 Services Provided: Neonatal Nursery Not Provided SVCS PROV2235
02100 Services Provided: Nuclear Medicine Provided by Staff SVCS PROV2245
02200 Services Provided: Obstetrics Not Provided SVCS PROV2265
02360 Services Provided: Occupational Therapy Provided under Arrangement SVCS PROV2270
01400 Services Provided: Cardiac - Thoracic Surgery Provided by Staff SVCS PROV2285
02240 Services Provided: Optometric Not Provided SVCS PROV2295
02260 Services Provided: Operating Rooms Provided by Staff SVCS PROV2300
02080 Services Provided: Organ Transplant (Not Medicare Provided under Arrangement SVCS PROV2315
02420 Services Provided: Outpatient Provided by Staff SVCS PROV2350
02480 Services Provided: Outpatient Surgery Provided by Staff SVCS PROV2355
02500 Services Provided: Pediatric Not Provided SVCS PROV2360
00430 Services Provided: Pharmacy Provided by Staff SVCS PROV2365
02820 Services Provided: Physical Therapy Provided by Staff SVCS PROV2370
02720 Services Provided: Postoperative Recovery Room Provided by Staff SVCS PROV2410
01230 Services Provided: Psychiatric - Adult Inpatient Not Provided SVCS PROV2415
01650 Services Provided: Radiology (Diagnostic) Provided by Staff and Arrangement
SVCS PROV2440
03230 Services Provided: Radiology (Therapeutic) Provided by Staff and Arrangement
SVCS PROV2445
02920 Services Provided: Respiratory Care Provided by Staff SVCS PROV2455
01630 Services Provided: Trauma Center (Designated) Not Provided SVCS PROV2475
02980 Services Provided: Social Provided by Staff SVCS PROV2485
03060 Services Provided: Speech Pathology Provided by Staff SVCS PROV2505
00080 SSA County Code 490 PROV2695
00220 SSA State Code 10 PROV2700
00230 State Region Code LAN PROV2710
00070 Compliance: Status In Compliance PROV2715
04790 Swing Bed Switch Swing Bed service not approved PROV2795
04800 Swing Bed Size Code PROV2800
00290 General Type of Control Code Proprietary PROV2885
00410 Type of Facility Short - Term PROV2890
00300 ZIP Code 33410 PROV2905
00210 State Abbreviation FL PROV3230
00790 Current Survey Ever Swing Bed No PROV3550
00270 Termination Date / Expiration Date 1 DATE PROV4500
00260 Termination Code 1 Active PROV4770
01310 Services Provided: Audiology Provided under Arrangement SVCS PROV6160
01440 Services Provided: Chemotherapy Provided by Staff SVCS PROV6170
01560 Services Provided: CT Scanner Provided by Staff SVCS PROV6175
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Line Line Description TypeValue Field Name
01720 Services Provided: Emergency Dept(Dedicated) Provided by Staff and Arrangement
SVCS PROV6180
01760 Services Provided: Extracorporeal Shock Wave Provided under Arrangement SVCS PROV6185
01820 Services Provided: Gerontological Specialty Not Provided SVCS PROV6190
02020 Services Provided: ICU Neonatal Not Provided SVCS PROV6195
02520 Services Provided: ICU Pediatric Not Provided SVCS PROV6200
03120 Services Provided: ICU Surgical Provided by Staff SVCS PROV6205
02000 Services Provided: Magnetic Resonance Imaging Provided by Staff SVCS PROV6210
02060 Services Provided: Neurosurgical Services Provided by Staff and Arrangement
SVCS PROV6215
02220 Services Provided: Ophthalmic Surgery Not Provided SVCS PROV6220
02280 Services Provided: Orthopedic Surgery Provided by Staff SVCS PROV6225
02540 Services Provided: PET Scan Services Provided under Arrangement SVCS PROV6230
01740 Services Provided: Psychiatric - Emergency Not Provided SVCS PROV6235
02740 Services Provided: Psychiatric Child/Adolescent Not Provided SVCS PROV6240
01780 Services Provided: Psychiatric - Forensic Not Provided SVCS PROV6245
01800 Services Provided: Psychiatric - Geriatric Not Provided SVCS PROV6250
02440 Services Provided: Psychiatric - Outpatient Not Provided SVCS PROV6255
02870 Services Provided: Reconstructive Surgery Not Provided SVCS PROV6260
02460 Services Provided: Rehabilitation Outpatient Provided by Staff SVCS PROV6265
01420 Services Provided: CARF Inpatient Rehabilitation C Not Provided SVCS PROV6270
01950 Services Provided: Transplant Center (Medicare Cer Not Provided SVCS PROV6275
03280 Services Provided: Urgent Care Center Services Not Provided SVCS PROV6280
03770 Medical Technologist Count 20 FTES PROV6290
03840 Nuclear Medicine Technician Count 2 FTES PROV6295
04310 Psychologist Count 0 FTES PROV6300
04440 Radiology Technician Count 27 FTES PROV6305
00840 Fax Phone Number PROV9015
04230 Physician Assistants (PA) 0 PROV9020
00330 CBSA Urban Rural Indicator U SSAMSASZ
100168
BOCA RATON REGIONAL HOSPITAL
BOCA RATON, FL 33486
00320 FIPS County Code 12099 FIPCNTY
00310 FIPS State Code 12 FIPSTATE
00280 Type of Action Code 2 PR201301
00370 Affiliated Resident Program: Allopathic N PR201302
00380 Affiliated Resident Program: Dental N PR201303
00390 Affiliated Resident Program: Osteopathic N PR201304
00400 Affiliated Resident Program: Other N PR201305
01380 Services: Cardiac Catheterization Lab Code 0 PR201314
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Line Line Description TypeValue Field Name
00340 Accreditation Effective Date 10/10/2009 DATE PROV0000
00350 Accreditation Expiration Date 10/10/2015 DATE PROV0005
00360 Accreditation Type Code JCAHO PROV0010
00020 Provider Category Code Hospital PROV0075
00010 Provider Category Subtype Code Short Term PROV0085
00030 Change of Ownership Count 0 PROV0095
00040 Change of Ownership Date DATE PROV0100
00060 Compliance: Plan of Correction N PROV0220
00750 Compliance: Life Safety Code N CMPL PROV0240
00770 Compliance: Scope of Service N CMPL PROV0280
00780 Compliance: Technical Personnel Waiver N CMPL PROV0285
00720 Compliance: 24 Hour Registered Nurse N CMPL PROV0290
00090 Cross Ref Provider Number CODE PROV0300
04850 Date of Validation Survey DATE PROV0450
00110 Eligibility Switch Yes PROV0455
00850 Fiscal Year Ending Date 0630 PROV0485
00100 Certification Date 10/20/1992 DATE PROV0500
00130 Intermediary Carrier Code 00090 PROV0605
00930 Medical School Affiliation No Affiliation PROV0645
00140 Medicare or Medicaid Vendor Number 010141900 CODE PROV0655
00990 Meets 1861 Definition N CMPL PROV0670
01000 Type of Non-Participating Provider PROV0690
00630 Beds-Total 400 BEDS PROV0740
00490 Beds - Total Certified 400 BEDS PROV0755
03490 Certified Registered Nurse Anesthetists (CRNA) 0 FTES PROV0760
03530 Dietitians 6 FTES PROV0820
04460 Respiratory Therapists 17 FTES PROV0950
03670 Licensed Practical/Vocational Nurses 28 FTES PROV0955
03750 Medical Social Workers 5 FTES PROV0975
03880 Nurse Practitioners 0 FTES PROV1015
03920 Occupational Therapists 3 FTES PROV1050
03430 Other Personnel 1045 FTES PROV1075
04450 Registered Pharmacists 18 FTES PROV1100
04210 Physicians 0 FTES PROV1110
04330 Physical Therapists 17 FTES PROV1125
04470 Registered Nurses 404 FTES PROV1145
04270 Physicians (Residents) 0 FTES PROV1165
04640 Speech Pathologist or Audiologist 4 FTES PROV1220
00480 Regional Override # 1 (Number Beds) No PROV1545
03380 Regional Override # 2 (Staffing) No PROV1550
01010 Regional Override # 3 (Nurse - Bed) No PROV1555
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Line Line Description TypeValue Field Name
00150 Participation Date 07/27/1967 DATE PROV1565
01080 Program Participation 3 PROV1570
00250 Telephone Number 5613625002 PROV1605
00160 Prior Change of Ownership Date DATE PROV1615
00170 Intermediary Carrier Prior Code 00090 CODE PROV1620
00950 Medicare or Medicaid Participating Provider Switch Y PROV1670
00180 Provider Number 100168 CODE PROV1680
01100 Psychiatric Unit Bed Count 0 BEDS PROV1690
01110 Psychiatric Unit Effective Date DATE PROV1695
01120 Psychiatric Unit Switch No PROV1700
01130 Psychiatric Unit Termination Code PROV1705
01140 Psychiatric Unit Termination Date DATE PROV1710
00190 Region Code Atlanta PROV1725
01150 Rehabilitation Unit Bed Count 0 BEDS PROV1730
01160 Rehabilitation Unit Effective Date DATE PROV1735
01170 Rehabilitation Unit Switch No PROV1740
01180 Rehabilitation Unit Termination Code PROV1745
01190 Rehabilitation Unit Termination Date DATE PROV1750
01200 Related Provider Number CODE PROV1755
00200 Skeleton Record Switch N PROV2045
01210 Services Provided: Acute Renal Dialysis Provided by Staff SVCS PROV2055
01260 Services Provided: Alcohol and/or Drug Not Provided SVCS PROV2065
01280 Services Provided: Anesthesia Provided by Staff SVCS PROV2070
01360 Services Provided: Burn Care Unit Not Provided SVCS PROV2090
01460 Services Provided: Chiropractic Not Provided SVCS PROV2100
01530 Services Provided: ICU Cardiac (non-surgical) Provided by Staff SVCS PROV2110
01580 Services Provided: Dental Not Provided SVCS PROV2120
01670 Services Provided: Dietary Provided by Staff SVCS PROV2130
01930 Services Provided: ICU Medical/Surgical Provided by Staff SVCS PROV2185
01880 Services Provided: Inpatient Surgical Provided by Staff SVCS PROV2190
01510 Services Provided: Clinical Laboratory 1 SVCS PROV2200
02040 Services Provided: Neonatal Nursery Not Provided SVCS PROV2235
02100 Services Provided: Nuclear Medicine Provided by Staff SVCS PROV2245
02200 Services Provided: Obstetrics Not Provided SVCS PROV2265
02360 Services Provided: Occupational Therapy Provided by Staff SVCS PROV2270
01400 Services Provided: Cardiac - Thoracic Surgery Not Provided SVCS PROV2285
02240 Services Provided: Optometric Not Provided SVCS PROV2295
02260 Services Provided: Operating Rooms Provided by Staff SVCS PROV2300
02080 Services Provided: Organ Transplant (Not Medicare Not Provided SVCS PROV2315
02420 Services Provided: Outpatient Provided by Staff SVCS PROV2350
02480 Services Provided: Outpatient Surgery Provided by Staff SVCS PROV2355
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Line Line Description TypeValue Field Name
02500 Services Provided: Pediatric Provided by Staff SVCS PROV2360
00430 Services Provided: Pharmacy Provided by Staff SVCS PROV2365
02820 Services Provided: Physical Therapy Provided by Staff SVCS PROV2370
02720 Services Provided: Postoperative Recovery Room Provided by Staff SVCS PROV2410
01230 Services Provided: Psychiatric - Adult Inpatient Provided by Staff SVCS PROV2415
01650 Services Provided: Radiology (Diagnostic) Provided by Staff SVCS PROV2440
03230 Services Provided: Radiology (Therapeutic) Provided by Staff SVCS PROV2445
02920 Services Provided: Respiratory Care Provided by Staff SVCS PROV2455
01630 Services Provided: Trauma Center (Designated) Not Provided SVCS PROV2475
02980 Services Provided: Social Provided by Staff SVCS PROV2485
03060 Services Provided: Speech Pathology Provided by Staff SVCS PROV2505
00080 SSA County Code 490 PROV2695
00220 SSA State Code 10 PROV2700
00230 State Region Code LAN PROV2710
00070 Compliance: Status In Compliance PROV2715
04790 Swing Bed Switch Swing Bed service not approved PROV2795
04800 Swing Bed Size Code PROV2800
00290 General Type of Control Code Voluntary Non-Profit - Private PROV2885
00410 Type of Facility Short - Term PROV2890
00300 ZIP Code 33486 PROV2905
00210 State Abbreviation FL PROV3230
00790 Current Survey Ever Swing Bed No PROV3550
00270 Termination Date / Expiration Date 1 DATE PROV4500
00260 Termination Code 1 Active PROV4770
01310 Services Provided: Audiology Not Provided SVCS PROV6160
01440 Services Provided: Chemotherapy Not Provided SVCS PROV6170
01560 Services Provided: CT Scanner Not Provided SVCS PROV6175
01720 Services Provided: Emergency Dept(Dedicated) Provided by Staff SVCS PROV6180
01760 Services Provided: Extracorporeal Shock Wave Not Provided SVCS PROV6185
01820 Services Provided: Gerontological Specialty Not Provided SVCS PROV6190
02020 Services Provided: ICU Neonatal Not Provided SVCS PROV6195
02520 Services Provided: ICU Pediatric Not Provided SVCS PROV6200
03120 Services Provided: ICU Surgical Not Provided SVCS PROV6205
02000 Services Provided: Magnetic Resonance Imaging Not Provided SVCS PROV6210
02060 Services Provided: Neurosurgical Services Not Provided SVCS PROV6215
02220 Services Provided: Ophthalmic Surgery Not Provided SVCS PROV6220
02280 Services Provided: Orthopedic Surgery Not Provided SVCS PROV6225
02540 Services Provided: PET Scan Services Not Provided SVCS PROV6230
01740 Services Provided: Psychiatric - Emergency Not Provided SVCS PROV6235
02740 Services Provided: Psychiatric Child/Adolescent Not Provided SVCS PROV6240
01780 Services Provided: Psychiatric - Forensic Not Provided SVCS PROV6245
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01800 Services Provided: Psychiatric - Geriatric Not Provided SVCS PROV6250
02440 Services Provided: Psychiatric - Outpatient Not Provided SVCS PROV6255
02870 Services Provided: Reconstructive Surgery Not Provided SVCS PROV6260
02460 Services Provided: Rehabilitation Outpatient Not Provided SVCS PROV6265
01420 Services Provided: CARF Inpatient Rehabilitation C Not Provided SVCS PROV6270
01950 Services Provided: Transplant Center (Medicare Cer Not Provided SVCS PROV6275
03280 Services Provided: Urgent Care Center Services Not Provided SVCS PROV6280
03770 Medical Technologist Count 0 FTES PROV6290
03840 Nuclear Medicine Technician Count 0 FTES PROV6295
04310 Psychologist Count 0 FTES PROV6300
04440 Radiology Technician Count 0 FTES PROV6305
00840 Fax Phone Number PROV9015
04230 Physician Assistants (PA) 0 PROV9020
00330 CBSA Urban Rural Indicator U SSAMSASZ
100144
EVERGLADES MEMORIAL HOSPITAL
PAHOKEE, FL 33476
00320 FIPS County Code 12099 FIPCNTY
00310 FIPS State Code 12 FIPSTATE
00280 Type of Action Code 2 PR201301
00370 Affiliated Resident Program: Allopathic N PR201302
00380 Affiliated Resident Program: Dental N PR201303
00390 Affiliated Resident Program: Osteopathic N PR201304
00400 Affiliated Resident Program: Other N PR201305
01380 Services: Cardiac Catheterization Lab Code 0 PR201314
00340 Accreditation Effective Date 01/31/1995 DATE PROV0000
00350 Accreditation Expiration Date 01/31/1998 DATE PROV0005
00360 Accreditation Type Code JCAHO PROV0010
00020 Provider Category Code Hospital PROV0075
00010 Provider Category Subtype Code Short Term PROV0085
00030 Change of Ownership Count 2 PROV0095
00040 Change of Ownership Date DATE PROV0100
00060 Compliance: Plan of Correction N PROV0220
00750 Compliance: Life Safety Code N CMPL PROV0240
00770 Compliance: Scope of Service N CMPL PROV0280
00780 Compliance: Technical Personnel Waiver N CMPL PROV0285
00720 Compliance: 24 Hour Registered Nurse N CMPL PROV0290
00090 Cross Ref Provider Number CODE PROV0300
04850 Date of Validation Survey DATE PROV0450
00110 Eligibility Switch Yes PROV0455
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Line Line Description TypeValue Field Name
00850 Fiscal Year Ending Date 0930 PROV0485
00100 Certification Date 02/15/1992 DATE PROV0500
00130 Intermediary Carrier Code 00090 PROV0605
00930 Medical School Affiliation No Affiliation PROV0645
00140 Medicare or Medicaid Vendor Number CODE PROV0655
00990 Meets 1861 Definition N CMPL PROV0670
01000 Type of Non-Participating Provider PROV0690
00630 Beds-Total 63 BEDS PROV0740
00490 Beds - Total Certified 63 BEDS PROV0755
03490 Certified Registered Nurse Anesthetists (CRNA) 2 FTES PROV0760
03530 Dietitians 1 FTES PROV0820
04460 Respiratory Therapists 0 FTES PROV0950
03670 Licensed Practical/Vocational Nurses 0 FTES PROV0955
03750 Medical Social Workers 1 FTES PROV0975
03880 Nurse Practitioners 0 FTES PROV1015
03920 Occupational Therapists 0 FTES PROV1050
03430 Other Personnel 316 FTES PROV1075
04450 Registered Pharmacists 0 FTES PROV1100
04210 Physicians 4 FTES PROV1110
04330 Physical Therapists 1 FTES PROV1125
04470 Registered Nurses 60 FTES PROV1145
04270 Physicians (Residents) 0 FTES PROV1165
04640 Speech Pathologist or Audiologist 0 FTES PROV1220
00480 Regional Override # 1 (Number Beds) No PROV1545
03380 Regional Override # 2 (Staffing) Yes PROV1550
01010 Regional Override # 3 (Nurse - Bed) Yes PROV1555
00150 Participation Date 07/01/1966 DATE PROV1565
01080 Program Participation 3 PROV1570
00250 Telephone Number 4079245200 PROV1605
00160 Prior Change of Ownership Date 10/01/1986 DATE PROV1615
00170 Intermediary Carrier Prior Code CODE PROV1620
00950 Medicare or Medicaid Participating Provider Switch Y PROV1670
00180 Provider Number 100144 CODE PROV1680
01100 Psychiatric Unit Bed Count 0 BEDS PROV1690
01110 Psychiatric Unit Effective Date DATE PROV1695
01120 Psychiatric Unit Switch No PROV1700
01130 Psychiatric Unit Termination Code PROV1705
01140 Psychiatric Unit Termination Date DATE PROV1710
00190 Region Code Atlanta PROV1725
01150 Rehabilitation Unit Bed Count 0 BEDS PROV1730
01160 Rehabilitation Unit Effective Date DATE PROV1735
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01170 Rehabilitation Unit Switch No PROV1740
01180 Rehabilitation Unit Termination Code PROV1745
01190 Rehabilitation Unit Termination Date DATE PROV1750
01200 Related Provider Number CODE PROV1755
00200 Skeleton Record Switch N PROV2045
01210 Services Provided: Acute Renal Dialysis Not Provided SVCS PROV2055
01260 Services Provided: Alcohol and/or Drug Not Provided SVCS PROV2065
01280 Services Provided: Anesthesia Provided by Staff SVCS PROV2070
01360 Services Provided: Burn Care Unit Not Provided SVCS PROV2090
01460 Services Provided: Chiropractic Not Provided SVCS PROV2100
01530 Services Provided: ICU Cardiac (non-surgical) Provided by Staff SVCS PROV2110
01580 Services Provided: Dental Not Provided SVCS PROV2120
01670 Services Provided: Dietary Provided by Staff SVCS PROV2130
01930 Services Provided: ICU Medical/Surgical Provided by Staff SVCS PROV2185
01880 Services Provided: Inpatient Surgical Provided by Staff SVCS PROV2190
01510 Services Provided: Clinical Laboratory 1 SVCS PROV2200
02040 Services Provided: Neonatal Nursery Provided by Staff SVCS PROV2235
02100 Services Provided: Nuclear Medicine Provided by Staff SVCS PROV2245
02200 Services Provided: Obstetrics Provided by Staff SVCS PROV2265
02360 Services Provided: Occupational Therapy Not Provided SVCS PROV2270
01400 Services Provided: Cardiac - Thoracic Surgery Not Provided SVCS PROV2285
02240 Services Provided: Optometric Not Provided SVCS PROV2295
02260 Services Provided: Operating Rooms Provided by Staff SVCS PROV2300
02080 Services Provided: Organ Transplant (Not Medicare Not Provided SVCS PROV2315
02420 Services Provided: Outpatient Provided by Staff SVCS PROV2350
02480 Services Provided: Outpatient Surgery Provided by Staff SVCS PROV2355
02500 Services Provided: Pediatric Provided by Staff SVCS PROV2360
00430 Services Provided: Pharmacy Provided under Arrangement SVCS PROV2365
02820 Services Provided: Physical Therapy Provided by Staff SVCS PROV2370
02720 Services Provided: Postoperative Recovery Room Provided by Staff SVCS PROV2410
01230 Services Provided: Psychiatric - Adult Inpatient Not Provided SVCS PROV2415
01650 Services Provided: Radiology (Diagnostic) Provided by Staff SVCS PROV2440
03230 Services Provided: Radiology (Therapeutic) Not Provided SVCS PROV2445
02920 Services Provided: Respiratory Care Provided under Arrangement SVCS PROV2455
01630 Services Provided: Trauma Center (Designated) Not Provided SVCS PROV2475
02980 Services Provided: Social Provided by Staff SVCS PROV2485
03060 Services Provided: Speech Pathology Not Provided SVCS PROV2505
00080 SSA County Code 490 PROV2695
00220 SSA State Code 10 PROV2700
00230 State Region Code LAN PROV2710
00070 Compliance: Status In Compliance PROV2715
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Line Line Description TypeValue Field Name
04790 Swing Bed Switch Swing Bed service not approved PROV2795
04800 Swing Bed Size Code PROV2800
00290 General Type of Control Code Voluntary Non-Profit - Private PROV2885
00410 Type of Facility Short - Term PROV2890
00300 ZIP Code 33476 PROV2905
00210 State Abbreviation FL PROV3230
00790 Current Survey Ever Swing Bed No PROV3550
00270 Termination Date / Expiration Date 1 04/09/1998 DATE PROV4500
00260 Termination Code 1 Voluntary - Reimburse PROV4770
01310 Services Provided: Audiology Not Provided SVCS PROV6160
01440 Services Provided: Chemotherapy Not Provided SVCS PROV6170
01560 Services Provided: CT Scanner Not Provided SVCS PROV6175
01720 Services Provided: Emergency Dept(Dedicated) Provided under Arrangement SVCS PROV6180
01760 Services Provided: Extracorporeal Shock Wave Not Provided SVCS PROV6185
01820 Services Provided: Gerontological Specialty Not Provided SVCS PROV6190
02020 Services Provided: ICU Neonatal Not Provided SVCS PROV6195
02520 Services Provided: ICU Pediatric Not Provided SVCS PROV6200
03120 Services Provided: ICU Surgical Not Provided SVCS PROV6205
02000 Services Provided: Magnetic Resonance Imaging Not Provided SVCS PROV6210
02060 Services Provided: Neurosurgical Services Not Provided SVCS PROV6215
02220 Services Provided: Ophthalmic Surgery Not Provided SVCS PROV6220
02280 Services Provided: Orthopedic Surgery Not Provided SVCS PROV6225
02540 Services Provided: PET Scan Services Not Provided SVCS PROV6230
01740 Services Provided: Psychiatric - Emergency Not Provided SVCS PROV6235
02740 Services Provided: Psychiatric Child/Adolescent Not Provided SVCS PROV6240
01780 Services Provided: Psychiatric - Forensic Not Provided SVCS PROV6245
01800 Services Provided: Psychiatric - Geriatric Not Provided SVCS PROV6250
02440 Services Provided: Psychiatric - Outpatient Not Provided SVCS PROV6255
02870 Services Provided: Reconstructive Surgery Not Provided SVCS PROV6260
02460 Services Provided: Rehabilitation Outpatient Not Provided SVCS PROV6265
01420 Services Provided: CARF Inpatient Rehabilitation C Not Provided SVCS PROV6270
01950 Services Provided: Transplant Center (Medicare Cer Not Provided SVCS PROV6275
03280 Services Provided: Urgent Care Center Services Not Provided SVCS PROV6280
03770 Medical Technologist Count 0 FTES PROV6290
03840 Nuclear Medicine Technician Count 0 FTES PROV6295
04310 Psychologist Count 0 FTES PROV6300
04440 Radiology Technician Count 0 FTES PROV6305
00840 Fax Phone Number PROV9015
04230 Physician Assistants (PA) 0 PROV9020
00330 CBSA Urban Rural Indicator U SSAMSASZ
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100130
LAKESIDE MEDICAL CENTER
BELLE GLADE, FL 33430
00320 FIPS County Code 12099 FIPCNTY
00310 FIPS State Code 12 FIPSTATE
00280 Type of Action Code 5 PR201301
00370 Affiliated Resident Program: Allopathic N PR201302
00380 Affiliated Resident Program: Dental N PR201303
00390 Affiliated Resident Program: Osteopathic N PR201304
00400 Affiliated Resident Program: Other N PR201305
01380 Services: Cardiac Catheterization Lab Code 0 PR201314
00340 Accreditation Effective Date 02/27/2010 DATE PROV0000
00350 Accreditation Expiration Date 12/14/2015 DATE PROV0005
00360 Accreditation Type Code JCAHO PROV0010
00020 Provider Category Code Hospital PROV0075
00010 Provider Category Subtype Code Short Term PROV0085
00030 Change of Ownership Count 3 PROV0095
00040 Change of Ownership Date 04/30/2004 DATE PROV0100
00060 Compliance: Plan of Correction N PROV0220
00750 Compliance: Life Safety Code N CMPL PROV0240
00770 Compliance: Scope of Service N CMPL PROV0280
00780 Compliance: Technical Personnel Waiver N CMPL PROV0285
00720 Compliance: 24 Hour Registered Nurse N CMPL PROV0290
00090 Cross Ref Provider Number CODE PROV0300
04850 Date of Validation Survey 04/14/2010 DATE PROV0450
00110 Eligibility Switch Yes PROV0455
00850 Fiscal Year Ending Date 0930 PROV0485
00100 Certification Date 04/14/2010 DATE PROV0500
00130 Intermediary Carrier Code 00090 PROV0605
00930 Medical School Affiliation No Affiliation PROV0645
00140 Medicare or Medicaid Vendor Number 010144300 CODE PROV0655
00990 Meets 1861 Definition N CMPL PROV0670
01000 Type of Non-Participating Provider PROV0690
00630 Beds-Total 70 BEDS PROV0740
00490 Beds - Total Certified 70 BEDS PROV0755
03490 Certified Registered Nurse Anesthetists (CRNA) 0 FTES PROV0760
03530 Dietitians 0 FTES PROV0820
04460 Respiratory Therapists 5 FTES PROV0950
03670 Licensed Practical/Vocational Nurses 11 FTES PROV0955
03750 Medical Social Workers 0 FTES PROV0975
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Line Line Description TypeValue Field Name
03880 Nurse Practitioners 0 FTES PROV1015
03920 Occupational Therapists 0 FTES PROV1050
03430 Other Personnel 137 FTES PROV1075
04450 Registered Pharmacists 2 FTES PROV1100
04210 Physicians 12 FTES PROV1110
04330 Physical Therapists 0 FTES PROV1125
04470 Registered Nurses 69 FTES PROV1145
04270 Physicians (Residents) 0 FTES PROV1165
04640 Speech Pathologist or Audiologist 0 FTES PROV1220
00480 Regional Override # 1 (Number Beds) No PROV1545
03380 Regional Override # 2 (Staffing) No PROV1550
01010 Regional Override # 3 (Nurse - Bed) No PROV1555
00150 Participation Date 07/01/1966 DATE PROV1565
01080 Program Participation 3 PROV1570
00250 Telephone Number 5619966571 PROV1605
00160 Prior Change of Ownership Date 04/30/2004 DATE PROV1615
00170 Intermediary Carrier Prior Code 00090 CODE PROV1620
00950 Medicare or Medicaid Participating Provider Switch Y PROV1670
00180 Provider Number 100130 CODE PROV1680
01100 Psychiatric Unit Bed Count 0 BEDS PROV1690
01110 Psychiatric Unit Effective Date DATE PROV1695
01120 Psychiatric Unit Switch No PROV1700
01130 Psychiatric Unit Termination Code PROV1705
01140 Psychiatric Unit Termination Date DATE PROV1710
00190 Region Code Atlanta PROV1725
01150 Rehabilitation Unit Bed Count 0 BEDS PROV1730
01160 Rehabilitation Unit Effective Date DATE PROV1735
01170 Rehabilitation Unit Switch No PROV1740
01180 Rehabilitation Unit Termination Code PROV1745
01190 Rehabilitation Unit Termination Date DATE PROV1750
01200 Related Provider Number CODE PROV1755
00200 Skeleton Record Switch N PROV2045
01210 Services Provided: Acute Renal Dialysis Provided under Arrangement SVCS PROV2055
01260 Services Provided: Alcohol and/or Drug Not Provided SVCS PROV2065
01280 Services Provided: Anesthesia Provided under Arrangement SVCS PROV2070
01360 Services Provided: Burn Care Unit Not Provided SVCS PROV2090
01460 Services Provided: Chiropractic Not Provided SVCS PROV2100
01530 Services Provided: ICU Cardiac (non-surgical) Provided by Staff SVCS PROV2110
01580 Services Provided: Dental Not Provided SVCS PROV2120
01670 Services Provided: Dietary Provided under Arrangement SVCS PROV2130
01930 Services Provided: ICU Medical/Surgical Provided by Staff SVCS PROV2185
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Line Line Description TypeValue Field Name
01880 Services Provided: Inpatient Surgical Provided by Staff SVCS PROV2190
01510 Services Provided: Clinical Laboratory 1 SVCS PROV2200
02040 Services Provided: Neonatal Nursery Provided by Staff SVCS PROV2235
02100 Services Provided: Nuclear Medicine Provided by Staff SVCS PROV2245
02200 Services Provided: Obstetrics Provided by Staff SVCS PROV2265
02360 Services Provided: Occupational Therapy Provided under Arrangement SVCS PROV2270
01400 Services Provided: Cardiac - Thoracic Surgery Not Provided SVCS PROV2285
02240 Services Provided: Optometric Not Provided SVCS PROV2295
02260 Services Provided: Operating Rooms Provided by Staff SVCS PROV2300
02080 Services Provided: Organ Transplant (Not Medicare Not Provided SVCS PROV2315
02420 Services Provided: Outpatient Provided by Staff SVCS PROV2350
02480 Services Provided: Outpatient Surgery Provided by Staff SVCS PROV2355
02500 Services Provided: Pediatric Provided by Staff SVCS PROV2360
00430 Services Provided: Pharmacy Provided by Staff SVCS PROV2365
02820 Services Provided: Physical Therapy Provided under Arrangement SVCS PROV2370
02720 Services Provided: Postoperative Recovery Room Provided by Staff SVCS PROV2410
01230 Services Provided: Psychiatric - Adult Inpatient Not Provided SVCS PROV2415
01650 Services Provided: Radiology (Diagnostic) Provided by Staff SVCS PROV2440
03230 Services Provided: Radiology (Therapeutic) Not Provided SVCS PROV2445
02920 Services Provided: Respiratory Care Provided by Staff SVCS PROV2455
01630 Services Provided: Trauma Center (Designated) Not Provided SVCS PROV2475
02980 Services Provided: Social Not Provided SVCS PROV2485
03060 Services Provided: Speech Pathology Provided under Arrangement SVCS PROV2505
00080 SSA County Code 490 PROV2695
00220 SSA State Code 10 PROV2700
00230 State Region Code LAN PROV2710
00070 Compliance: Status Not In Compliance PROV2715
04790 Swing Bed Switch Swing Bed service not approved PROV2795
04800 Swing Bed Size Code PROV2800
00290 General Type of Control Code Government - Hospital District/Auth
PROV2885
00410 Type of Facility Short - Term PROV2890
00300 ZIP Code 33430 PROV2905
00210 State Abbreviation FL PROV3230
00790 Current Survey Ever Swing Bed No PROV3550
00270 Termination Date / Expiration Date 1 DATE PROV4500
00260 Termination Code 1 Active PROV4770
01310 Services Provided: Audiology Not Provided SVCS PROV6160
01440 Services Provided: Chemotherapy Not Provided SVCS PROV6170
01560 Services Provided: CT Scanner Provided by Staff SVCS PROV6175
01720 Services Provided: Emergency Dept(Dedicated) Provided by Staff SVCS PROV6180
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Line Line Description TypeValue Field Name
01760 Services Provided: Extracorporeal Shock Wave Not Provided SVCS PROV6185
01820 Services Provided: Gerontological Specialty Not Provided SVCS PROV6190
02020 Services Provided: ICU Neonatal Not Provided SVCS PROV6195
02520 Services Provided: ICU Pediatric Not Provided SVCS PROV6200
03120 Services Provided: ICU Surgical Not Provided SVCS PROV6205
02000 Services Provided: Magnetic Resonance Imaging Provided by Staff SVCS PROV6210
02060 Services Provided: Neurosurgical Services Not Provided SVCS PROV6215
02220 Services Provided: Ophthalmic Surgery Not Provided SVCS PROV6220
02280 Services Provided: Orthopedic Surgery Not Provided SVCS PROV6225
02540 Services Provided: PET Scan Services Not Provided SVCS PROV6230
01740 Services Provided: Psychiatric - Emergency Not Provided SVCS PROV6235
02740 Services Provided: Psychiatric Child/Adolescent Not Provided SVCS PROV6240
01780 Services Provided: Psychiatric - Forensic Not Provided SVCS PROV6245
01800 Services Provided: Psychiatric - Geriatric Not Provided SVCS PROV6250
02440 Services Provided: Psychiatric - Outpatient Not Provided SVCS PROV6255
02870 Services Provided: Reconstructive Surgery Not Provided SVCS PROV6260
02460 Services Provided: Rehabilitation Outpatient Provided under Arrangement SVCS PROV6265
01420 Services Provided: CARF Inpatient Rehabilitation C Provided under Arrangement SVCS PROV6270
01950 Services Provided: Transplant Center (Medicare Cer Not Provided SVCS PROV6275
03280 Services Provided: Urgent Care Center Services Not Provided SVCS PROV6280
03770 Medical Technologist Count 6 FTES PROV6290
03840 Nuclear Medicine Technician Count 1 FTES PROV6295
04310 Psychologist Count 0 FTES PROV6300
04440 Radiology Technician Count 9 FTES PROV6305
00840 Fax Phone Number PROV9015
04230 Physician Assistants (PA) 0 PROV9020
00330 CBSA Urban Rural Indicator U SSAMSASZ
104033
FAIR OAKS HOSP OF BOCA/DELRAY
DELRAY BEACH, FL 33445
00320 FIPS County Code 12099 FIPCNTY
00310 FIPS State Code 12 FIPSTATE
00280 Type of Action Code 1 PR201301
00370 Affiliated Resident Program: Allopathic N PR201302
00380 Affiliated Resident Program: Dental N PR201303
00390 Affiliated Resident Program: Osteopathic N PR201304
00400 Affiliated Resident Program: Other N PR201305
01380 Services: Cardiac Catheterization Lab Code 0 PR201314
00340 Accreditation Effective Date DATE PROV0000
00350 Accreditation Expiration Date DATE PROV0005
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Line Line Description TypeValue Field Name
00360 Accreditation Type Code None PROV0010
00020 Provider Category Code Hospital PROV0075
00010 Provider Category Subtype Code Psychiatric PROV0085
00030 Change of Ownership Count 0 PROV0095
00040 Change of Ownership Date DATE PROV0100
00060 Compliance: Plan of Correction N PROV0220
00750 Compliance: Life Safety Code N CMPL PROV0240
00770 Compliance: Scope of Service N CMPL PROV0280
00780 Compliance: Technical Personnel Waiver N CMPL PROV0285
00720 Compliance: 24 Hour Registered Nurse N CMPL PROV0290
00090 Cross Ref Provider Number CODE PROV0300
04850 Date of Validation Survey DATE PROV0450
00110 Eligibility Switch Yes PROV0455
00850 Fiscal Year Ending Date 0531 PROV0485
00100 Certification Date 08/14/1985 DATE PROV0500
00130 Intermediary Carrier Code 00090 PROV0605
00930 Medical School Affiliation No Affiliation PROV0645
00140 Medicare or Medicaid Vendor Number CODE PROV0655
00990 Meets 1861 Definition N CMPL PROV0670
01000 Type of Non-Participating Provider PROV0690
00630 Beds-Total 72 BEDS PROV0740
00490 Beds - Total Certified 72 BEDS PROV0755
03490 Certified Registered Nurse Anesthetists (CRNA) 0 FTES PROV0760
03530 Dietitians 0 FTES PROV0820
04460 Respiratory Therapists 0 FTES PROV0950
03670 Licensed Practical/Vocational Nurses 0 FTES PROV0955
03750 Medical Social Workers 2 FTES PROV0975
03880 Nurse Practitioners 0 FTES PROV1015
03920 Occupational Therapists 2 FTES PROV1050
03430 Other Personnel 43 FTES PROV1075
04450 Registered Pharmacists 0 FTES PROV1100
04210 Physicians 0 FTES PROV1110
04330 Physical Therapists 0 FTES PROV1125
04470 Registered Nurses 18 FTES PROV1145
04270 Physicians (Residents) 0 FTES PROV1165
04640 Speech Pathologist or Audiologist 0 FTES PROV1220
00480 Regional Override # 1 (Number Beds) No PROV1545
03380 Regional Override # 2 (Staffing) No PROV1550
01010 Regional Override # 3 (Nurse - Bed) No PROV1555
00150 Participation Date 08/14/1985 DATE PROV1565
01080 Program Participation 1 PROV1570
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Line Line Description TypeValue Field Name
00250 Telephone Number 3054951000 PROV1605
00160 Prior Change of Ownership Date DATE PROV1615
00170 Intermediary Carrier Prior Code CODE PROV1620
00950 Medicare or Medicaid Participating Provider Switch Y PROV1670
00180 Provider Number 104033 CODE PROV1680
01100 Psychiatric Unit Bed Count 0 BEDS PROV1690
01110 Psychiatric Unit Effective Date DATE PROV1695
01120 Psychiatric Unit Switch No PROV1700
01130 Psychiatric Unit Termination Code PROV1705
01140 Psychiatric Unit Termination Date DATE PROV1710
00190 Region Code Atlanta PROV1725
01150 Rehabilitation Unit Bed Count 0 BEDS PROV1730
01160 Rehabilitation Unit Effective Date DATE PROV1735
01170 Rehabilitation Unit Switch No PROV1740
01180 Rehabilitation Unit Termination Code PROV1745
01190 Rehabilitation Unit Termination Date DATE PROV1750
01200 Related Provider Number CODE PROV1755
00200 Skeleton Record Switch N PROV2045
01210 Services Provided: Acute Renal Dialysis Not Provided SVCS PROV2055
01260 Services Provided: Alcohol and/or Drug Not Provided SVCS PROV2065
01280 Services Provided: Anesthesia Not Provided SVCS PROV2070
01360 Services Provided: Burn Care Unit Not Provided SVCS PROV2090
01460 Services Provided: Chiropractic Not Provided SVCS PROV2100
01530 Services Provided: ICU Cardiac (non-surgical) Not Provided SVCS PROV2110
01580 Services Provided: Dental Not Provided SVCS PROV2120
01670 Services Provided: Dietary Not Provided SVCS PROV2130
01930 Services Provided: ICU Medical/Surgical Not Provided SVCS PROV2185
01880 Services Provided: Inpatient Surgical Not Provided SVCS PROV2190
01510 Services Provided: Clinical Laboratory 2 SVCS PROV2200
02040 Services Provided: Neonatal Nursery Not Provided SVCS PROV2235
02100 Services Provided: Nuclear Medicine Provided under Arrangement SVCS PROV2245
02200 Services Provided: Obstetrics Not Provided SVCS PROV2265
02360 Services Provided: Occupational Therapy Provided by Staff SVCS PROV2270
01400 Services Provided: Cardiac - Thoracic Surgery Not Provided SVCS PROV2285
02240 Services Provided: Optometric Not Provided SVCS PROV2295
02260 Services Provided: Operating Rooms Not Provided SVCS PROV2300
02080 Services Provided: Organ Transplant (Not Medicare Not Provided SVCS PROV2315
02420 Services Provided: Outpatient Not Provided SVCS PROV2350
02480 Services Provided: Outpatient Surgery Not Provided SVCS PROV2355
02500 Services Provided: Pediatric Not Provided SVCS PROV2360
00430 Services Provided: Pharmacy Provided under Arrangement SVCS PROV2365
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Line Line Description TypeValue Field Name
02820 Services Provided: Physical Therapy Provided under Arrangement SVCS PROV2370
02720 Services Provided: Postoperative Recovery Room Not Provided SVCS PROV2410
01230 Services Provided: Psychiatric - Adult Inpatient Provided by Staff SVCS PROV2415
01650 Services Provided: Radiology (Diagnostic) Provided under Arrangement SVCS PROV2440
03230 Services Provided: Radiology (Therapeutic) Not Provided SVCS PROV2445
02920 Services Provided: Respiratory Care Not Provided SVCS PROV2455
01630 Services Provided: Trauma Center (Designated) Not Provided SVCS PROV2475
02980 Services Provided: Social Provided by Staff SVCS PROV2485
03060 Services Provided: Speech Pathology Provided under Arrangement SVCS PROV2505
00080 SSA County Code 490 PROV2695
00220 SSA State Code 10 PROV2700
00230 State Region Code MIA PROV2710
00070 Compliance: Status In Compliance PROV2715
04790 Swing Bed Switch Swing Bed service not approved PROV2795
04800 Swing Bed Size Code PROV2800
00290 General Type of Control Code Proprietary PROV2885
00410 Type of Facility Psychiatric PROV2890
00300 ZIP Code 33445 PROV2905
00210 State Abbreviation FL PROV3230
00790 Current Survey Ever Swing Bed No PROV3550
00270 Termination Date / Expiration Date 1 08/15/1985 DATE PROV4500
00260 Termination Code 1 Voluntary - Other PROV4770
01310 Services Provided: Audiology Not Provided SVCS PROV6160
01440 Services Provided: Chemotherapy Not Provided SVCS PROV6170
01560 Services Provided: CT Scanner Not Provided SVCS PROV6175
01720 Services Provided: Emergency Dept(Dedicated) Provided under Arrangement SVCS PROV6180
01760 Services Provided: Extracorporeal Shock Wave Not Provided SVCS PROV6185
01820 Services Provided: Gerontological Specialty Not Provided SVCS PROV6190
02020 Services Provided: ICU Neonatal Not Provided SVCS PROV6195
02520 Services Provided: ICU Pediatric Not Provided SVCS PROV6200
03120 Services Provided: ICU Surgical Not Provided SVCS PROV6205
02000 Services Provided: Magnetic Resonance Imaging Not Provided SVCS PROV6210
02060 Services Provided: Neurosurgical Services Not Provided SVCS PROV6215
02220 Services Provided: Ophthalmic Surgery Not Provided SVCS PROV6220
02280 Services Provided: Orthopedic Surgery Not Provided SVCS PROV6225
02540 Services Provided: PET Scan Services Not Provided SVCS PROV6230
01740 Services Provided: Psychiatric - Emergency Not Provided SVCS PROV6235
02740 Services Provided: Psychiatric Child/Adolescent Not Provided SVCS PROV6240
01780 Services Provided: Psychiatric - Forensic Not Provided SVCS PROV6245
01800 Services Provided: Psychiatric - Geriatric Not Provided SVCS PROV6250
02440 Services Provided: Psychiatric - Outpatient Not Provided SVCS PROV6255
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Line Line Description TypeValue Field Name
02870 Services Provided: Reconstructive Surgery Not Provided SVCS PROV6260
02460 Services Provided: Rehabilitation Outpatient Not Provided SVCS PROV6265
01420 Services Provided: CARF Inpatient Rehabilitation C Not Provided SVCS PROV6270
01950 Services Provided: Transplant Center (Medicare Cer Not Provided SVCS PROV6275
03280 Services Provided: Urgent Care Center Services Not Provided SVCS PROV6280
03770 Medical Technologist Count 0 FTES PROV6290
03840 Nuclear Medicine Technician Count 0 FTES PROV6295
04310 Psychologist Count 0 FTES PROV6300
04440 Radiology Technician Count 0 FTES PROV6305
00840 Fax Phone Number PROV9015
04230 Physician Assistants (PA) 0 PROV9020
00330 CBSA Urban Rural Indicator U SSAMSASZ
104060
FAIR OAKS PAVILLION AT DELRAY MEDICAL
DELRAY BEACH, FL 33484
00320 FIPS County Code 12099 FIPCNTY
00310 FIPS State Code 12 FIPSTATE
00280 Type of Action Code 2 PR201301
00370 Affiliated Resident Program: Allopathic N PR201302
00380 Affiliated Resident Program: Dental N PR201303
00390 Affiliated Resident Program: Osteopathic N PR201304
00400 Affiliated Resident Program: Other N PR201305
01380 Services: Cardiac Catheterization Lab Code 0 PR201314
00340 Accreditation Effective Date 08/09/1994 DATE PROV0000
00350 Accreditation Expiration Date 08/09/1997 DATE PROV0005
00360 Accreditation Type Code JCAHO PROV0010
00020 Provider Category Code Hospital PROV0075
00010 Provider Category Subtype Code Psychiatric PROV0085
00030 Change of Ownership Count 1 PROV0095
00040 Change of Ownership Date 03/01/1999 DATE PROV0100
00060 Compliance: Plan of Correction N PROV0220
00750 Compliance: Life Safety Code N CMPL PROV0240
00770 Compliance: Scope of Service N CMPL PROV0280
00780 Compliance: Technical Personnel Waiver N CMPL PROV0285
00720 Compliance: 24 Hour Registered Nurse N CMPL PROV0290
00090 Cross Ref Provider Number CODE PROV0300
04850 Date of Validation Survey DATE PROV0450
00110 Eligibility Switch No PROV0455
00850 Fiscal Year Ending Date 0531 PROV0485
00100 Certification Date 01/11/1996 DATE PROV0500
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Line Line Description TypeValue Field Name
00130 Intermediary Carrier Code 52280 PROV0605
00930 Medical School Affiliation No Affiliation PROV0645
00140 Medicare or Medicaid Vendor Number CODE PROV0655
00990 Meets 1861 Definition N CMPL PROV0670
01000 Type of Non-Participating Provider PROV0690
00630 Beds-Total 102 BEDS PROV0740
00490 Beds - Total Certified 102 BEDS PROV0755
03490 Certified Registered Nurse Anesthetists (CRNA) 0 FTES PROV0760
03530 Dietitians 0 FTES PROV0820
04460 Respiratory Therapists 0 FTES PROV0950
03670 Licensed Practical/Vocational Nurses 3 FTES PROV0955
03750 Medical Social Workers 6 FTES PROV0975
03880 Nurse Practitioners 0 FTES PROV1015
03920 Occupational Therapists 0 FTES PROV1050
03430 Other Personnel 50 FTES PROV1075
04450 Registered Pharmacists 0 FTES PROV1100
04210 Physicians 0 FTES PROV1110
04330 Physical Therapists 0 FTES PROV1125
04470 Registered Nurses 25 FTES PROV1145
04270 Physicians (Residents) 0 FTES PROV1165
04640 Speech Pathologist or Audiologist 0 FTES PROV1220
00480 Regional Override # 1 (Number Beds) No PROV1545
03380 Regional Override # 2 (Staffing) No PROV1550
01010 Regional Override # 3 (Nurse - Bed) No PROV1555
00150 Participation Date 05/03/1992 DATE PROV1565
01080 Program Participation 1 PROV1570
00250 Telephone Number 4074951000 PROV1605
00160 Prior Change of Ownership Date DATE PROV1615
00170 Intermediary Carrier Prior Code 00090 CODE PROV1620
00950 Medicare or Medicaid Participating Provider Switch Y PROV1670
00180 Provider Number 104060 CODE PROV1680
01100 Psychiatric Unit Bed Count 0 BEDS PROV1690
01110 Psychiatric Unit Effective Date DATE PROV1695
01120 Psychiatric Unit Switch No PROV1700
01130 Psychiatric Unit Termination Code PROV1705
01140 Psychiatric Unit Termination Date DATE PROV1710
00190 Region Code Atlanta PROV1725
01150 Rehabilitation Unit Bed Count 0 BEDS PROV1730
01160 Rehabilitation Unit Effective Date DATE PROV1735
01170 Rehabilitation Unit Switch No PROV1740
01180 Rehabilitation Unit Termination Code PROV1745
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01190 Rehabilitation Unit Termination Date DATE PROV1750
01200 Related Provider Number CODE PROV1755
00200 Skeleton Record Switch N PROV2045
01210 Services Provided: Acute Renal Dialysis Not Provided SVCS PROV2055
01260 Services Provided: Alcohol and/or Drug Provided by Staff and Arrangement
SVCS PROV2065
01280 Services Provided: Anesthesia Not Provided SVCS PROV2070
01360 Services Provided: Burn Care Unit Not Provided SVCS PROV2090
01460 Services Provided: Chiropractic Not Provided SVCS PROV2100
01530 Services Provided: ICU Cardiac (non-surgical) Not Provided SVCS PROV2110
01580 Services Provided: Dental Not Provided SVCS PROV2120
01670 Services Provided: Dietary Provided under Arrangement SVCS PROV2130
01930 Services Provided: ICU Medical/Surgical Not Provided SVCS PROV2185
01880 Services Provided: Inpatient Surgical Not Provided SVCS PROV2190
01510 Services Provided: Clinical Laboratory 2 SVCS PROV2200
02040 Services Provided: Neonatal Nursery Not Provided SVCS PROV2235
02100 Services Provided: Nuclear Medicine Not Provided SVCS PROV2245
02200 Services Provided: Obstetrics Not Provided SVCS PROV2265
02360 Services Provided: Occupational Therapy Not Provided SVCS PROV2270
01400 Services Provided: Cardiac - Thoracic Surgery Not Provided SVCS PROV2285
02240 Services Provided: Optometric Not Provided SVCS PROV2295
02260 Services Provided: Operating Rooms Not Provided SVCS PROV2300
02080 Services Provided: Organ Transplant (Not Medicare Not Provided SVCS PROV2315
02420 Services Provided: Outpatient Provided by Staff SVCS PROV2350
02480 Services Provided: Outpatient Surgery Not Provided SVCS PROV2355
02500 Services Provided: Pediatric Not Provided SVCS PROV2360
00430 Services Provided: Pharmacy Provided under Arrangement SVCS PROV2365
02820 Services Provided: Physical Therapy Not Provided SVCS PROV2370
02720 Services Provided: Postoperative Recovery Room Not Provided SVCS PROV2410
01230 Services Provided: Psychiatric - Adult Inpatient Provided by Staff SVCS PROV2415
01650 Services Provided: Radiology (Diagnostic) Provided under Arrangement SVCS PROV2440
03230 Services Provided: Radiology (Therapeutic) Not Provided SVCS PROV2445
02920 Services Provided: Respiratory Care Not Provided SVCS PROV2455
01630 Services Provided: Trauma Center (Designated) Not Provided SVCS PROV2475
02980 Services Provided: Social Provided by Staff SVCS PROV2485
03060 Services Provided: Speech Pathology Not Provided SVCS PROV2505
00080 SSA County Code 490 PROV2695
00220 SSA State Code 10 PROV2700
00230 State Region Code LAN PROV2710
00070 Compliance: Status In Compliance PROV2715
04790 Swing Bed Switch Swing Bed service not approved PROV2795
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Line Line Description TypeValue Field Name
04800 Swing Bed Size Code PROV2800
00290 General Type of Control Code Proprietary PROV2885
00410 Type of Facility Psychiatric PROV2890
00300 ZIP Code 33484 PROV2905
00210 State Abbreviation FL PROV3230
00790 Current Survey Ever Swing Bed No PROV3550
00270 Termination Date / Expiration Date 1 03/01/1999 DATE PROV4500
00260 Termination Code 1 Voluntary - Reimburse PROV4770
01310 Services Provided: Audiology Not Provided SVCS PROV6160
01440 Services Provided: Chemotherapy Not Provided SVCS PROV6170
01560 Services Provided: CT Scanner Not Provided SVCS PROV6175
01720 Services Provided: Emergency Dept(Dedicated) Provided under Arrangement SVCS PROV6180
01760 Services Provided: Extracorporeal Shock Wave Not Provided SVCS PROV6185
01820 Services Provided: Gerontological Specialty Not Provided SVCS PROV6190
02020 Services Provided: ICU Neonatal Not Provided SVCS PROV6195
02520 Services Provided: ICU Pediatric Not Provided SVCS PROV6200
03120 Services Provided: ICU Surgical Not Provided SVCS PROV6205
02000 Services Provided: Magnetic Resonance Imaging Not Provided SVCS PROV6210
02060 Services Provided: Neurosurgical Services Not Provided SVCS PROV6215
02220 Services Provided: Ophthalmic Surgery Not Provided SVCS PROV6220
02280 Services Provided: Orthopedic Surgery Not Provided SVCS PROV6225
02540 Services Provided: PET Scan Services Not Provided SVCS PROV6230
01740 Services Provided: Psychiatric - Emergency Not Provided SVCS PROV6235
02740 Services Provided: Psychiatric Child/Adolescent Not Provided SVCS PROV6240
01780 Services Provided: Psychiatric - Forensic Not Provided SVCS PROV6245
01800 Services Provided: Psychiatric - Geriatric Not Provided SVCS PROV6250
02440 Services Provided: Psychiatric - Outpatient Not Provided SVCS PROV6255
02870 Services Provided: Reconstructive Surgery Not Provided SVCS PROV6260
02460 Services Provided: Rehabilitation Outpatient Not Provided SVCS PROV6265
01420 Services Provided: CARF Inpatient Rehabilitation C Not Provided SVCS PROV6270
01950 Services Provided: Transplant Center (Medicare Cer Not Provided SVCS PROV6275
03280 Services Provided: Urgent Care Center Services Not Provided SVCS PROV6280
03770 Medical Technologist Count 0 FTES PROV6290
03840 Nuclear Medicine Technician Count 0 FTES PROV6295
04310 Psychologist Count 0 FTES PROV6300
04440 Radiology Technician Count 0 FTES PROV6305
00840 Fax Phone Number PROV9015
04230 Physician Assistants (PA) 0 PROV9020
00330 CBSA Urban Rural Indicator U SSAMSASZ
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104061
GLENBEIGH HOSP OF THE PALM BEACHES INC
WEST PALM BEACH, FL 33407
00320 FIPS County Code 12099 FIPCNTY
00310 FIPS State Code 12 FIPSTATE
00280 Type of Action Code 2 PR201301
00370 Affiliated Resident Program: Allopathic N PR201302
00380 Affiliated Resident Program: Dental N PR201303
00390 Affiliated Resident Program: Osteopathic N PR201304
00400 Affiliated Resident Program: Other N PR201305
01380 Services: Cardiac Catheterization Lab Code 0 PR201314
00340 Accreditation Effective Date 01/08/1992 DATE PROV0000
00350 Accreditation Expiration Date 01/07/1994 DATE PROV0005
00360 Accreditation Type Code JCAHO PROV0010
00020 Provider Category Code Hospital PROV0075
00010 Provider Category Subtype Code Psychiatric PROV0085
00030 Change of Ownership Count 0 PROV0095
00040 Change of Ownership Date DATE PROV0100
00060 Compliance: Plan of Correction N PROV0220
00750 Compliance: Life Safety Code N CMPL PROV0240
00770 Compliance: Scope of Service N CMPL PROV0280
00780 Compliance: Technical Personnel Waiver N CMPL PROV0285
00720 Compliance: 24 Hour Registered Nurse N CMPL PROV0290
00090 Cross Ref Provider Number CODE PROV0300
04850 Date of Validation Survey DATE PROV0450
00110 Eligibility Switch No PROV0455
00850 Fiscal Year Ending Date 0630 PROV0485
00100 Certification Date 02/24/1994 DATE PROV0500
00130 Intermediary Carrier Code 00090 PROV0605
00930 Medical School Affiliation No Affiliation PROV0645
00140 Medicare or Medicaid Vendor Number CODE PROV0655
00990 Meets 1861 Definition N CMPL PROV0670
01000 Type of Non-Participating Provider PROV0690
00630 Beds-Total 60 BEDS PROV0740
00490 Beds - Total Certified 60 BEDS PROV0755
03490 Certified Registered Nurse Anesthetists (CRNA) 0 FTES PROV0760
03530 Dietitians 0 FTES PROV0820
04460 Respiratory Therapists 0 FTES PROV0950
03670 Licensed Practical/Vocational Nurses 0 FTES PROV0955
03750 Medical Social Workers 4 FTES PROV0975
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Line Line Description TypeValue Field Name
03880 Nurse Practitioners 0 FTES PROV1015
03920 Occupational Therapists 1 FTES PROV1050
03430 Other Personnel 0 FTES PROV1075
04450 Registered Pharmacists 0 FTES PROV1100
04210 Physicians 3 FTES PROV1110
04330 Physical Therapists 0 FTES PROV1125
04470 Registered Nurses 12 FTES PROV1145
04270 Physicians (Residents) 0 FTES PROV1165
04640 Speech Pathologist or Audiologist 0 FTES PROV1220
00480 Regional Override # 1 (Number Beds) No PROV1545
03380 Regional Override # 2 (Staffing) Yes PROV1550
01010 Regional Override # 3 (Nurse - Bed) No PROV1555
00150 Participation Date 03/22/1993 DATE PROV1565
01080 Program Participation 1 PROV1570
00250 Telephone Number 4078485500 PROV1605
00160 Prior Change of Ownership Date DATE PROV1615
00170 Intermediary Carrier Prior Code CODE PROV1620
00950 Medicare or Medicaid Participating Provider Switch Y PROV1670
00180 Provider Number 104061 CODE PROV1680
01100 Psychiatric Unit Bed Count 0 BEDS PROV1690
01110 Psychiatric Unit Effective Date DATE PROV1695
01120 Psychiatric Unit Switch No PROV1700
01130 Psychiatric Unit Termination Code PROV1705
01140 Psychiatric Unit Termination Date DATE PROV1710
00190 Region Code Atlanta PROV1725
01150 Rehabilitation Unit Bed Count 0 BEDS PROV1730
01160 Rehabilitation Unit Effective Date DATE PROV1735
01170 Rehabilitation Unit Switch No PROV1740
01180 Rehabilitation Unit Termination Code PROV1745
01190 Rehabilitation Unit Termination Date DATE PROV1750
01200 Related Provider Number CODE PROV1755
00200 Skeleton Record Switch N PROV2045
01210 Services Provided: Acute Renal Dialysis Not Provided SVCS PROV2055
01260 Services Provided: Alcohol and/or Drug Provided by Staff SVCS PROV2065
01280 Services Provided: Anesthesia Not Provided SVCS PROV2070
01360 Services Provided: Burn Care Unit Not Provided SVCS PROV2090
01460 Services Provided: Chiropractic Not Provided SVCS PROV2100
01530 Services Provided: ICU Cardiac (non-surgical) Not Provided SVCS PROV2110
01580 Services Provided: Dental Not Provided SVCS PROV2120
01670 Services Provided: Dietary Provided by Staff SVCS PROV2130
01930 Services Provided: ICU Medical/Surgical Not Provided SVCS PROV2185
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Line Line Description TypeValue Field Name
01880 Services Provided: Inpatient Surgical Not Provided SVCS PROV2190
01510 Services Provided: Clinical Laboratory 2 SVCS PROV2200
02040 Services Provided: Neonatal Nursery Not Provided SVCS PROV2235
02100 Services Provided: Nuclear Medicine Not Provided SVCS PROV2245
02200 Services Provided: Obstetrics Not Provided SVCS PROV2265
02360 Services Provided: Occupational Therapy Provided by Staff SVCS PROV2270
01400 Services Provided: Cardiac - Thoracic Surgery Not Provided SVCS PROV2285
02240 Services Provided: Optometric Not Provided SVCS PROV2295
02260 Services Provided: Operating Rooms Not Provided SVCS PROV2300
02080 Services Provided: Organ Transplant (Not Medicare Not Provided SVCS PROV2315
02420 Services Provided: Outpatient Provided by Staff and Arrangement
SVCS PROV2350
02480 Services Provided: Outpatient Surgery Not Provided SVCS PROV2355
02500 Services Provided: Pediatric Not Provided SVCS PROV2360
00430 Services Provided: Pharmacy Provided under Arrangement SVCS PROV2365
02820 Services Provided: Physical Therapy Provided under Arrangement SVCS PROV2370
02720 Services Provided: Postoperative Recovery Room Not Provided SVCS PROV2410
01230 Services Provided: Psychiatric - Adult Inpatient Provided by Staff and Arrangement
SVCS PROV2415
01650 Services Provided: Radiology (Diagnostic) Provided under Arrangement SVCS PROV2440
03230 Services Provided: Radiology (Therapeutic) Not Provided SVCS PROV2445
02920 Services Provided: Respiratory Care Not Provided SVCS PROV2455
01630 Services Provided: Trauma Center (Designated) Not Provided SVCS PROV2475
02980 Services Provided: Social Provided by Staff SVCS PROV2485
03060 Services Provided: Speech Pathology Provided under Arrangement SVCS PROV2505
00080 SSA County Code 490 PROV2695
00220 SSA State Code 10 PROV2700
00230 State Region Code LAN PROV2710
00070 Compliance: Status In Compliance PROV2715
04790 Swing Bed Switch Swing Bed service not approved PROV2795
04800 Swing Bed Size Code PROV2800
00290 General Type of Control Code Proprietary PROV2885
00410 Type of Facility Psychiatric PROV2890
00300 ZIP Code 33407 PROV2905
00210 State Abbreviation FL PROV3230
00790 Current Survey Ever Swing Bed No PROV3550
00270 Termination Date / Expiration Date 1 04/27/1994 DATE PROV4500
00260 Termination Code 1 Voluntary - Merge,Close PROV4770
01310 Services Provided: Audiology Not Provided SVCS PROV6160
01440 Services Provided: Chemotherapy Not Provided SVCS PROV6170
01560 Services Provided: CT Scanner Not Provided SVCS PROV6175
01720 Services Provided: Emergency Dept(Dedicated) Provided under Arrangement SVCS PROV6180
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Line Line Description TypeValue Field Name
01760 Services Provided: Extracorporeal Shock Wave Not Provided SVCS PROV6185
01820 Services Provided: Gerontological Specialty Not Provided SVCS PROV6190
02020 Services Provided: ICU Neonatal Not Provided SVCS PROV6195
02520 Services Provided: ICU Pediatric Not Provided SVCS PROV6200
03120 Services Provided: ICU Surgical Not Provided SVCS PROV6205
02000 Services Provided: Magnetic Resonance Imaging Not Provided SVCS PROV6210
02060 Services Provided: Neurosurgical Services Not Provided SVCS PROV6215
02220 Services Provided: Ophthalmic Surgery Not Provided SVCS PROV6220
02280 Services Provided: Orthopedic Surgery Not Provided SVCS PROV6225
02540 Services Provided: PET Scan Services Not Provided SVCS PROV6230
01740 Services Provided: Psychiatric - Emergency Not Provided SVCS PROV6235
02740 Services Provided: Psychiatric Child/Adolescent Not Provided SVCS PROV6240
01780 Services Provided: Psychiatric - Forensic Not Provided SVCS PROV6245
01800 Services Provided: Psychiatric - Geriatric Not Provided SVCS PROV6250
02440 Services Provided: Psychiatric - Outpatient Not Provided SVCS PROV6255
02870 Services Provided: Reconstructive Surgery Not Provided SVCS PROV6260
02460 Services Provided: Rehabilitation Outpatient Not Provided SVCS PROV6265
01420 Services Provided: CARF Inpatient Rehabilitation C Not Provided SVCS PROV6270
01950 Services Provided: Transplant Center (Medicare Cer Not Provided SVCS PROV6275
03280 Services Provided: Urgent Care Center Services Not Provided SVCS PROV6280
03770 Medical Technologist Count 0 FTES PROV6290
03840 Nuclear Medicine Technician Count 0 FTES PROV6295
04310 Psychologist Count 0 FTES PROV6300
04440 Radiology Technician Count 0 FTES PROV6305
00840 Fax Phone Number PROV9015
04230 Physician Assistants (PA) 0 PROV9020
00330 CBSA Urban Rural Indicator U SSAMSASZ
100080
JFK MEDICAL CENTER
ATLANTIS, FL 33462
00320 FIPS County Code 12099 FIPCNTY
00310 FIPS State Code 12 FIPSTATE
00280 Type of Action Code 2 PR201301
00370 Affiliated Resident Program: Allopathic N PR201302
00380 Affiliated Resident Program: Dental N PR201303
00390 Affiliated Resident Program: Osteopathic N PR201304
00400 Affiliated Resident Program: Other Y PR201305
01380 Services: Cardiac Catheterization Lab Code 1 PR201314
00340 Accreditation Effective Date 10/03/2009 DATE PROV0000
00350 Accreditation Expiration Date 09/20/2015 DATE PROV0005
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Line Line Description TypeValue Field Name
00360 Accreditation Type Code JCAHO PROV0010
00020 Provider Category Code Hospital PROV0075
00010 Provider Category Subtype Code Short Term PROV0085
00030 Change of Ownership Count 4 PROV0095
00040 Change of Ownership Date DATE PROV0100
00060 Compliance: Plan of Correction N PROV0220
00750 Compliance: Life Safety Code N CMPL PROV0240
00770 Compliance: Scope of Service N CMPL PROV0280
00780 Compliance: Technical Personnel Waiver N CMPL PROV0285
00720 Compliance: 24 Hour Registered Nurse N CMPL PROV0290
00090 Cross Ref Provider Number CODE PROV0300
04850 Date of Validation Survey DATE PROV0450
00110 Eligibility Switch Yes PROV0455
00850 Fiscal Year Ending Date 0630 PROV0485
00100 Certification Date 01/28/2010 DATE PROV0500
00130 Intermediary Carrier Code 52280 PROV0605
00930 Medical School Affiliation No Affiliation PROV0645
00140 Medicare or Medicaid Vendor Number 010146000 CODE PROV0655
00990 Meets 1861 Definition N CMPL PROV0670
01000 Type of Non-Participating Provider PROV0690
00630 Beds-Total 460 BEDS PROV0740
00490 Beds - Total Certified 460 BEDS PROV0755
03490 Certified Registered Nurse Anesthetists (CRNA) 0 FTES PROV0760
03530 Dietitians 1 FTES PROV0820
04460 Respiratory Therapists 49 FTES PROV0950
03670 Licensed Practical/Vocational Nurses 40 FTES PROV0955
03750 Medical Social Workers 3 FTES PROV0975
03880 Nurse Practitioners 3 FTES PROV1015
03920 Occupational Therapists 0 FTES PROV1050
03430 Other Personnel 568 FTES PROV1075
04450 Registered Pharmacists 24 FTES PROV1100
04210 Physicians 2 FTES PROV1110
04330 Physical Therapists 6 FTES PROV1125
04470 Registered Nurses 558 FTES PROV1145
04270 Physicians (Residents) 3 FTES PROV1165
04640 Speech Pathologist or Audiologist 1 FTES PROV1220
00480 Regional Override # 1 (Number Beds) No PROV1545
03380 Regional Override # 2 (Staffing) No PROV1550
01010 Regional Override # 3 (Nurse - Bed) No PROV1555
00150 Participation Date 07/01/1966 DATE PROV1565
01080 Program Participation 3 PROV1570
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Line Line Description TypeValue Field Name
00250 Telephone Number 5619657300 PROV1605
00160 Prior Change of Ownership Date DATE PROV1615
00170 Intermediary Carrier Prior Code 52280 CODE PROV1620
00950 Medicare or Medicaid Participating Provider Switch Y PROV1670
00180 Provider Number 100080 CODE PROV1680
01100 Psychiatric Unit Bed Count 31 BEDS PROV1690
01110 Psychiatric Unit Effective Date 07/01/2012 DATE PROV1695
01120 Psychiatric Unit Switch Yes PROV1700
01130 Psychiatric Unit Termination Code Active PROV1705
01140 Psychiatric Unit Termination Date DATE PROV1710
00190 Region Code Atlanta PROV1725
01150 Rehabilitation Unit Bed Count 0 BEDS PROV1730
01160 Rehabilitation Unit Effective Date DATE PROV1735
01170 Rehabilitation Unit Switch No PROV1740
01180 Rehabilitation Unit Termination Code PROV1745
01190 Rehabilitation Unit Termination Date DATE PROV1750
01200 Related Provider Number CODE PROV1755
00200 Skeleton Record Switch N PROV2045
01210 Services Provided: Acute Renal Dialysis Provided under Arrangement SVCS PROV2055
01260 Services Provided: Alcohol and/or Drug Not Provided SVCS PROV2065
01280 Services Provided: Anesthesia Provided under Arrangement SVCS PROV2070
01360 Services Provided: Burn Care Unit Not Provided SVCS PROV2090
01460 Services Provided: Chiropractic Not Provided SVCS PROV2100
01530 Services Provided: ICU Cardiac (non-surgical) Provided by Staff SVCS PROV2110
01580 Services Provided: Dental Not Provided SVCS PROV2120
01670 Services Provided: Dietary Provided under Arrangement SVCS PROV2130
01930 Services Provided: ICU Medical/Surgical Provided by Staff SVCS PROV2185
01880 Services Provided: Inpatient Surgical Provided by Staff SVCS PROV2190
01510 Services Provided: Clinical Laboratory 2 SVCS PROV2200
02040 Services Provided: Neonatal Nursery Not Provided SVCS PROV2235
02100 Services Provided: Nuclear Medicine Provided by Staff SVCS PROV2245
02200 Services Provided: Obstetrics Not Provided SVCS PROV2265
02360 Services Provided: Occupational Therapy Not Provided SVCS PROV2270
01400 Services Provided: Cardiac - Thoracic Surgery Provided by Staff SVCS PROV2285
02240 Services Provided: Optometric Not Provided SVCS PROV2295
02260 Services Provided: Operating Rooms Provided by Staff SVCS PROV2300
02080 Services Provided: Organ Transplant (Not Medicare Not Provided SVCS PROV2315
02420 Services Provided: Outpatient Provided by Staff SVCS PROV2350
02480 Services Provided: Outpatient Surgery Provided by Staff SVCS PROV2355
02500 Services Provided: Pediatric Not Provided SVCS PROV2360
00430 Services Provided: Pharmacy Provided by Staff SVCS PROV2365
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Line Line Description TypeValue Field Name
02820 Services Provided: Physical Therapy Provided by Staff SVCS PROV2370
02720 Services Provided: Postoperative Recovery Room Provided by Staff SVCS PROV2410
01230 Services Provided: Psychiatric - Adult Inpatient Not Provided SVCS PROV2415
01650 Services Provided: Radiology (Diagnostic) Provided by Staff SVCS PROV2440
03230 Services Provided: Radiology (Therapeutic) Provided by Staff SVCS PROV2445
02920 Services Provided: Respiratory Care Provided by Staff SVCS PROV2455
01630 Services Provided: Trauma Center (Designated) Not Provided SVCS PROV2475
02980 Services Provided: Social Provided by Staff SVCS PROV2485
03060 Services Provided: Speech Pathology Provided by Staff SVCS PROV2505
00080 SSA County Code 490 PROV2695
00220 SSA State Code 10 PROV2700
00230 State Region Code LAN PROV2710
00070 Compliance: Status In Compliance PROV2715
04790 Swing Bed Switch Swing Bed service not approved PROV2795
04800 Swing Bed Size Code PROV2800
00290 General Type of Control Code Proprietary PROV2885
00410 Type of Facility Short - Term PROV2890
00300 ZIP Code 33462 PROV2905
00210 State Abbreviation FL PROV3230
00790 Current Survey Ever Swing Bed No PROV3550
00270 Termination Date / Expiration Date 1 DATE PROV4500
00260 Termination Code 1 Active PROV4770
01310 Services Provided: Audiology Not Provided SVCS PROV6160
01440 Services Provided: Chemotherapy Provided by Staff SVCS PROV6170
01560 Services Provided: CT Scanner Provided by Staff SVCS PROV6175
01720 Services Provided: Emergency Dept(Dedicated) Provided by Staff SVCS PROV6180
01760 Services Provided: Extracorporeal Shock Wave Not Provided SVCS PROV6185
01820 Services Provided: Gerontological Specialty Not Provided SVCS PROV6190
02020 Services Provided: ICU Neonatal Not Provided SVCS PROV6195
02520 Services Provided: ICU Pediatric Not Provided SVCS PROV6200
03120 Services Provided: ICU Surgical Provided by Staff SVCS PROV6205
02000 Services Provided: Magnetic Resonance Imaging Provided by Staff SVCS PROV6210
02060 Services Provided: Neurosurgical Services Provided by Staff SVCS PROV6215
02220 Services Provided: Ophthalmic Surgery Provided by Staff SVCS PROV6220
02280 Services Provided: Orthopedic Surgery Provided by Staff SVCS PROV6225
02540 Services Provided: PET Scan Services Not Provided SVCS PROV6230
01740 Services Provided: Psychiatric - Emergency Provided by Staff SVCS PROV6235
02740 Services Provided: Psychiatric Child/Adolescent Not Provided SVCS PROV6240
01780 Services Provided: Psychiatric - Forensic Not Provided SVCS PROV6245
01800 Services Provided: Psychiatric - Geriatric Not Provided SVCS PROV6250
02440 Services Provided: Psychiatric - Outpatient Not Provided SVCS PROV6255
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Line Line Description TypeValue Field Name
02870 Services Provided: Reconstructive Surgery Provided by Staff SVCS PROV6260
02460 Services Provided: Rehabilitation Outpatient Provided by Staff SVCS PROV6265
01420 Services Provided: CARF Inpatient Rehabilitation C Not Provided SVCS PROV6270
01950 Services Provided: Transplant Center (Medicare Cer Not Provided SVCS PROV6275
03280 Services Provided: Urgent Care Center Services Not Provided SVCS PROV6280
03770 Medical Technologist Count 0 FTES PROV6290
03840 Nuclear Medicine Technician Count 7 FTES PROV6295
04310 Psychologist Count 0 FTES PROV6300
04440 Radiology Technician Count 62 FTES PROV6305
00840 Fax Phone Number PROV9015
04230 Physician Assistants (PA) 0 PROV9020
00330 CBSA Urban Rural Indicator U SSAMSASZ
100010
ST MARYS HOSPITAL INC
WEST PALM BEACH, FL 33407
00320 FIPS County Code 12099 FIPCNTY
00310 FIPS State Code 12 FIPSTATE
00280 Type of Action Code 5 PR201301
00370 Affiliated Resident Program: Allopathic N PR201302
00380 Affiliated Resident Program: Dental N PR201303
00390 Affiliated Resident Program: Osteopathic N PR201304
00400 Affiliated Resident Program: Other N PR201305
01380 Services: Cardiac Catheterization Lab Code 0 PR201314
00340 Accreditation Effective Date 01/24/1995 DATE PROV0000
00350 Accreditation Expiration Date 01/24/1998 DATE PROV0005
00360 Accreditation Type Code JCAHO PROV0010
00020 Provider Category Code Hospital PROV0075
00010 Provider Category Subtype Code Short Term PROV0085
00030 Change of Ownership Count 0 PROV0095
00040 Change of Ownership Date DATE PROV0100
00060 Compliance: Plan of Correction Y PROV0220
00750 Compliance: Life Safety Code N CMPL PROV0240
00770 Compliance: Scope of Service N CMPL PROV0280
00780 Compliance: Technical Personnel Waiver N CMPL PROV0285
00720 Compliance: 24 Hour Registered Nurse N CMPL PROV0290
00090 Cross Ref Provider Number CODE PROV0300
04850 Date of Validation Survey 03/17/1995 DATE PROV0450
00110 Eligibility Switch Yes PROV0455
00850 Fiscal Year Ending Date 0630 PROV0485
00100 Certification Date 03/17/1995 DATE PROV0500
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Line Line Description TypeValue Field Name
00130 Intermediary Carrier Code 00090 PROV0605
00930 Medical School Affiliation No Affiliation PROV0645
00140 Medicare or Medicaid Vendor Number CODE PROV0655
00990 Meets 1861 Definition N CMPL PROV0670
01000 Type of Non-Participating Provider PROV0690
00630 Beds-Total 433 BEDS PROV0740
00490 Beds - Total Certified 433 BEDS PROV0755
03490 Certified Registered Nurse Anesthetists (CRNA) 0 FTES PROV0760
03530 Dietitians 4 FTES PROV0820
04460 Respiratory Therapists 34 FTES PROV0950
03670 Licensed Practical/Vocational Nurses 46 FTES PROV0955
03750 Medical Social Workers 8 FTES PROV0975
03880 Nurse Practitioners 0 FTES PROV1015
03920 Occupational Therapists 8 FTES PROV1050
03430 Other Personnel 572 FTES PROV1075
04450 Registered Pharmacists 16 FTES PROV1100
04210 Physicians 0 FTES PROV1110
04330 Physical Therapists 15 FTES PROV1125
04470 Registered Nurses 577 FTES PROV1145
04270 Physicians (Residents) 0 FTES PROV1165
04640 Speech Pathologist or Audiologist 6 FTES PROV1220
00480 Regional Override # 1 (Number Beds) No PROV1545
03380 Regional Override # 2 (Staffing) No PROV1550
01010 Regional Override # 3 (Nurse - Bed) No PROV1555
00150 Participation Date 07/01/1966 DATE PROV1565
01080 Program Participation 3 PROV1570
00250 Telephone Number 4078446300 PROV1605
00160 Prior Change of Ownership Date DATE PROV1615
00170 Intermediary Carrier Prior Code CODE PROV1620
00950 Medicare or Medicaid Participating Provider Switch Y PROV1670
00180 Provider Number 100010 CODE PROV1680
01100 Psychiatric Unit Bed Count 40 BEDS PROV1690
01110 Psychiatric Unit Effective Date 07/01/1992 DATE PROV1695
01120 Psychiatric Unit Switch Yes PROV1700
01130 Psychiatric Unit Termination Code Voluntary-Other PROV1705
01140 Psychiatric Unit Termination Date 07/01/2001 DATE PROV1710
00190 Region Code Atlanta PROV1725
01150 Rehabilitation Unit Bed Count 23 BEDS PROV1730
01160 Rehabilitation Unit Effective Date 07/01/1994 DATE PROV1735
01170 Rehabilitation Unit Switch Yes PROV1740
01180 Rehabilitation Unit Termination Code Voluntary-Other PROV1745
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01190 Rehabilitation Unit Termination Date 07/01/2001 DATE PROV1750
01200 Related Provider Number CODE PROV1755
00200 Skeleton Record Switch N PROV2045
01210 Services Provided: Acute Renal Dialysis Provided under Arrangement SVCS PROV2055
01260 Services Provided: Alcohol and/or Drug Provided by Staff SVCS PROV2065
01280 Services Provided: Anesthesia Provided under Arrangement SVCS PROV2070
01360 Services Provided: Burn Care Unit Not Provided SVCS PROV2090
01460 Services Provided: Chiropractic Not Provided SVCS PROV2100
01530 Services Provided: ICU Cardiac (non-surgical) Provided by Staff SVCS PROV2110
01580 Services Provided: Dental Not Provided SVCS PROV2120
01670 Services Provided: Dietary Provided by Staff SVCS PROV2130
01930 Services Provided: ICU Medical/Surgical Provided by Staff SVCS PROV2185
01880 Services Provided: Inpatient Surgical Provided by Staff SVCS PROV2190
01510 Services Provided: Clinical Laboratory 1 SVCS PROV2200
02040 Services Provided: Neonatal Nursery Provided by Staff SVCS PROV2235
02100 Services Provided: Nuclear Medicine Provided under Arrangement SVCS PROV2245
02200 Services Provided: Obstetrics Provided by Staff SVCS PROV2265
02360 Services Provided: Occupational Therapy Provided by Staff SVCS PROV2270
01400 Services Provided: Cardiac - Thoracic Surgery Not Provided SVCS PROV2285
02240 Services Provided: Optometric Not Provided SVCS PROV2295
02260 Services Provided: Operating Rooms Provided by Staff SVCS PROV2300
02080 Services Provided: Organ Transplant (Not Medicare Not Provided SVCS PROV2315
02420 Services Provided: Outpatient Provided by Staff and Arrangement
SVCS PROV2350
02480 Services Provided: Outpatient Surgery Provided by Staff and Arrangement
SVCS PROV2355
02500 Services Provided: Pediatric Provided by Staff SVCS PROV2360
00430 Services Provided: Pharmacy Provided by Staff SVCS PROV2365
02820 Services Provided: Physical Therapy Provided by Staff SVCS PROV2370
02720 Services Provided: Postoperative Recovery Room Provided by Staff and Arrangement
SVCS PROV2410
01230 Services Provided: Psychiatric - Adult Inpatient Provided by Staff SVCS PROV2415
01650 Services Provided: Radiology (Diagnostic) Provided under Arrangement SVCS PROV2440
03230 Services Provided: Radiology (Therapeutic) Provided under Arrangement SVCS PROV2445
02920 Services Provided: Respiratory Care Provided by Staff SVCS PROV2455
01630 Services Provided: Trauma Center (Designated) Provided by Staff SVCS PROV2475
02980 Services Provided: Social Provided by Staff SVCS PROV2485
03060 Services Provided: Speech Pathology Provided by Staff SVCS PROV2505
00080 SSA County Code 490 PROV2695
00220 SSA State Code 10 PROV2700
00230 State Region Code LAN PROV2710
00070 Compliance: Status In Compliance PROV2715
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Line Line Description TypeValue Field Name
04790 Swing Bed Switch Swing Bed service not approved PROV2795
04800 Swing Bed Size Code PROV2800
00290 General Type of Control Code Voluntary Non-Profit - Private PROV2885
00410 Type of Facility Short - Term PROV2890
00300 ZIP Code 33407 PROV2905
00210 State Abbreviation FL PROV3230
00790 Current Survey Ever Swing Bed No PROV3550
00270 Termination Date / Expiration Date 1 07/01/2001 DATE PROV4500
00260 Termination Code 1 Voluntary - Other PROV4770
01310 Services Provided: Audiology Not Provided SVCS PROV6160
01440 Services Provided: Chemotherapy Not Provided SVCS PROV6170
01560 Services Provided: CT Scanner Not Provided SVCS PROV6175
01720 Services Provided: Emergency Dept(Dedicated) Provided by Staff SVCS PROV6180
01760 Services Provided: Extracorporeal Shock Wave Not Provided SVCS PROV6185
01820 Services Provided: Gerontological Specialty Not Provided SVCS PROV6190
02020 Services Provided: ICU Neonatal Not Provided SVCS PROV6195
02520 Services Provided: ICU Pediatric Not Provided SVCS PROV6200
03120 Services Provided: ICU Surgical Not Provided SVCS PROV6205
02000 Services Provided: Magnetic Resonance Imaging Not Provided SVCS PROV6210
02060 Services Provided: Neurosurgical Services Not Provided SVCS PROV6215
02220 Services Provided: Ophthalmic Surgery Not Provided SVCS PROV6220
02280 Services Provided: Orthopedic Surgery Not Provided SVCS PROV6225
02540 Services Provided: PET Scan Services Not Provided SVCS PROV6230
01740 Services Provided: Psychiatric - Emergency Not Provided SVCS PROV6235
02740 Services Provided: Psychiatric Child/Adolescent Not Provided SVCS PROV6240
01780 Services Provided: Psychiatric - Forensic Not Provided SVCS PROV6245
01800 Services Provided: Psychiatric - Geriatric Not Provided SVCS PROV6250
02440 Services Provided: Psychiatric - Outpatient Not Provided SVCS PROV6255
02870 Services Provided: Reconstructive Surgery Not Provided SVCS PROV6260
02460 Services Provided: Rehabilitation Outpatient Not Provided SVCS PROV6265
01420 Services Provided: CARF Inpatient Rehabilitation C Not Provided SVCS PROV6270
01950 Services Provided: Transplant Center (Medicare Cer Not Provided SVCS PROV6275
03280 Services Provided: Urgent Care Center Services Not Provided SVCS PROV6280
03770 Medical Technologist Count 0 FTES PROV6290
03840 Nuclear Medicine Technician Count 0 FTES PROV6295
04310 Psychologist Count 0 FTES PROV6300
04440 Radiology Technician Count 0 FTES PROV6305
00840 Fax Phone Number PROV9015
04230 Physician Assistants (PA) 0 PROV9020
00330 CBSA Urban Rural Indicator U SSAMSASZ
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Line Line Description TypeValue Field Name
100002
BETHESDA HOSPITAL EAST
BOYNTON BEACH, FL 33435
00320 FIPS County Code 12099 FIPCNTY
00310 FIPS State Code 12 FIPSTATE
00280 Type of Action Code 2 PR201301
00370 Affiliated Resident Program: Allopathic N PR201302
00380 Affiliated Resident Program: Dental N PR201303
00390 Affiliated Resident Program: Osteopathic N PR201304
00400 Affiliated Resident Program: Other N PR201305
01380 Services: Cardiac Catheterization Lab Code 1 PR201314
00340 Accreditation Effective Date 08/08/2009 DATE PROV0000
00350 Accreditation Expiration Date 08/24/2015 DATE PROV0005
00360 Accreditation Type Code JCAHO PROV0010
00020 Provider Category Code Hospital PROV0075
00010 Provider Category Subtype Code Short Term PROV0085
00030 Change of Ownership Count 3 PROV0095
00040 Change of Ownership Date DATE PROV0100
00060 Compliance: Plan of Correction N PROV0220
00750 Compliance: Life Safety Code N CMPL PROV0240
00770 Compliance: Scope of Service N CMPL PROV0280
00780 Compliance: Technical Personnel Waiver N CMPL PROV0285
00720 Compliance: 24 Hour Registered Nurse N CMPL PROV0290
00090 Cross Ref Provider Number CODE PROV0300
04850 Date of Validation Survey DATE PROV0450
00110 Eligibility Switch Yes PROV0455
00850 Fiscal Year Ending Date 0930 PROV0485
00100 Certification Date 12/07/1994 DATE PROV0500
00130 Intermediary Carrier Code 09101 PROV0605
00930 Medical School Affiliation No Affiliation PROV0645
00140 Medicare or Medicaid Vendor Number 010140100 CODE PROV0655
00990 Meets 1861 Definition N CMPL PROV0670
01000 Type of Non-Participating Provider PROV0690
00630 Beds-Total 481 BEDS PROV0740
00490 Beds - Total Certified 481 BEDS PROV0755
03490 Certified Registered Nurse Anesthetists (CRNA) 2 FTES PROV0760
03530 Dietitians 6 FTES PROV0820
04460 Respiratory Therapists 16 FTES PROV0950
03670 Licensed Practical/Vocational Nurses 60 FTES PROV0955
03750 Medical Social Workers 1 FTES PROV0975
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Line Line Description TypeValue Field Name
03880 Nurse Practitioners 0 FTES PROV1015
03920 Occupational Therapists 5 FTES PROV1050
03430 Other Personnel 997 FTES PROV1075
04450 Registered Pharmacists 16 FTES PROV1100
04210 Physicians 0 FTES PROV1110
04330 Physical Therapists 9 FTES PROV1125
04470 Registered Nurses 395 FTES PROV1145
04270 Physicians (Residents) 0 FTES PROV1165
04640 Speech Pathologist or Audiologist 1 FTES PROV1220
00480 Regional Override # 1 (Number Beds) Yes PROV1545
03380 Regional Override # 2 (Staffing) Yes PROV1550
01010 Regional Override # 3 (Nurse - Bed) No PROV1555
00150 Participation Date 07/01/1966 DATE PROV1565
01080 Program Participation 3 PROV1570
00250 Telephone Number 5617377733 PROV1605
00160 Prior Change of Ownership Date DATE PROV1615
00170 Intermediary Carrier Prior Code 09101 CODE PROV1620
00950 Medicare or Medicaid Participating Provider Switch Y PROV1670
00180 Provider Number 100002 CODE PROV1680
01100 Psychiatric Unit Bed Count 20 BEDS PROV1690
01110 Psychiatric Unit Effective Date 10/01/1989 DATE PROV1695
01120 Psychiatric Unit Switch Yes PROV1700
01130 Psychiatric Unit Termination Code Voluntary - Merger or Close PROV1705
01140 Psychiatric Unit Termination Date 01/25/2000 DATE PROV1710
00190 Region Code Atlanta PROV1725
01150 Rehabilitation Unit Bed Count 36 BEDS PROV1730
01160 Rehabilitation Unit Effective Date 10/01/2005 DATE PROV1735
01170 Rehabilitation Unit Switch Yes PROV1740
01180 Rehabilitation Unit Termination Code Active PROV1745
01190 Rehabilitation Unit Termination Date DATE PROV1750
01200 Related Provider Number CODE PROV1755
00200 Skeleton Record Switch N PROV2045
01210 Services Provided: Acute Renal Dialysis Provided by Staff SVCS PROV2055
01260 Services Provided: Alcohol and/or Drug Not Provided SVCS PROV2065
01280 Services Provided: Anesthesia Provided under Arrangement SVCS PROV2070
01360 Services Provided: Burn Care Unit Not Provided SVCS PROV2090
01460 Services Provided: Chiropractic Not Provided SVCS PROV2100
01530 Services Provided: ICU Cardiac (non-surgical) Provided by Staff SVCS PROV2110
01580 Services Provided: Dental Not Provided SVCS PROV2120
01670 Services Provided: Dietary Provided by Staff SVCS PROV2130
01930 Services Provided: ICU Medical/Surgical Provided by Staff SVCS PROV2185
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Line Line Description TypeValue Field Name
01880 Services Provided: Inpatient Surgical Provided by Staff SVCS PROV2190
01510 Services Provided: Clinical Laboratory 1 SVCS PROV2200
02040 Services Provided: Neonatal Nursery Provided by Staff SVCS PROV2235
02100 Services Provided: Nuclear Medicine Provided by Staff SVCS PROV2245
02200 Services Provided: Obstetrics Provided by Staff SVCS PROV2265
02360 Services Provided: Occupational Therapy Provided by Staff SVCS PROV2270
01400 Services Provided: Cardiac - Thoracic Surgery Not Provided SVCS PROV2285
02240 Services Provided: Optometric Not Provided SVCS PROV2295
02260 Services Provided: Operating Rooms Provided by Staff SVCS PROV2300
02080 Services Provided: Organ Transplant (Not Medicare Not Provided SVCS PROV2315
02420 Services Provided: Outpatient Provided by Staff SVCS PROV2350
02480 Services Provided: Outpatient Surgery Provided by Staff SVCS PROV2355
02500 Services Provided: Pediatric Provided by Staff SVCS PROV2360
00430 Services Provided: Pharmacy Provided by Staff SVCS PROV2365
02820 Services Provided: Physical Therapy Provided by Staff SVCS PROV2370
02720 Services Provided: Postoperative Recovery Room Provided by Staff SVCS PROV2410
01230 Services Provided: Psychiatric - Adult Inpatient Provided by Staff SVCS PROV2415
01650 Services Provided: Radiology (Diagnostic) Provided by Staff SVCS PROV2440
03230 Services Provided: Radiology (Therapeutic) Provided by Staff SVCS PROV2445
02920 Services Provided: Respiratory Care Provided by Staff SVCS PROV2455
01630 Services Provided: Trauma Center (Designated) Not Provided SVCS PROV2475
02980 Services Provided: Social Provided by Staff SVCS PROV2485
03060 Services Provided: Speech Pathology Provided by Staff SVCS PROV2505
00080 SSA County Code 490 PROV2695
00220 SSA State Code 10 PROV2700
00230 State Region Code LAN PROV2710
00070 Compliance: Status In Compliance PROV2715
04790 Swing Bed Switch Swing Bed service not approved PROV2795
04800 Swing Bed Size Code PROV2800
00290 General Type of Control Code Voluntary Non-Profit - Private PROV2885
00410 Type of Facility Short - Term PROV2890
00300 ZIP Code 33435 PROV2905
00210 State Abbreviation FL PROV3230
00790 Current Survey Ever Swing Bed No PROV3550
00270 Termination Date / Expiration Date 1 DATE PROV4500
00260 Termination Code 1 Active PROV4770
01310 Services Provided: Audiology Provided by Staff SVCS PROV6160
01440 Services Provided: Chemotherapy Provided by Staff SVCS PROV6170
01560 Services Provided: CT Scanner Not Provided SVCS PROV6175
01720 Services Provided: Emergency Dept(Dedicated) Provided by Staff and Arrangement
SVCS PROV6180
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Line Line Description TypeValue Field Name
01760 Services Provided: Extracorporeal Shock Wave Provided under Arrangement SVCS PROV6185
01820 Services Provided: Gerontological Specialty Not Provided SVCS PROV6190
02020 Services Provided: ICU Neonatal Provided by Staff SVCS PROV6195
02520 Services Provided: ICU Pediatric Provided by Staff SVCS PROV6200
03120 Services Provided: ICU Surgical Provided by Staff SVCS PROV6205
02000 Services Provided: Magnetic Resonance Imaging Provided by Staff SVCS PROV6210
02060 Services Provided: Neurosurgical Services Provided by Staff SVCS PROV6215
02220 Services Provided: Ophthalmic Surgery Provided by Staff SVCS PROV6220
02280 Services Provided: Orthopedic Surgery Provided by Staff SVCS PROV6225
02540 Services Provided: PET Scan Services Not Provided SVCS PROV6230
01740 Services Provided: Psychiatric - Emergency Not Provided SVCS PROV6235
02740 Services Provided: Psychiatric Child/Adolescent Not Provided SVCS PROV6240
01780 Services Provided: Psychiatric - Forensic Not Provided SVCS PROV6245
01800 Services Provided: Psychiatric - Geriatric Not Provided SVCS PROV6250
02440 Services Provided: Psychiatric - Outpatient Not Provided SVCS PROV6255
02870 Services Provided: Reconstructive Surgery Provided by Staff SVCS PROV6260
02460 Services Provided: Rehabilitation Outpatient Not Provided SVCS PROV6265
01420 Services Provided: CARF Inpatient Rehabilitation C Not Provided SVCS PROV6270
01950 Services Provided: Transplant Center (Medicare Cer Not Provided SVCS PROV6275
03280 Services Provided: Urgent Care Center Services Not Provided SVCS PROV6280
03770 Medical Technologist Count 0 FTES PROV6290
03840 Nuclear Medicine Technician Count 5 FTES PROV6295
04310 Psychologist Count 0 FTES PROV6300
04440 Radiology Technician Count 26 FTES PROV6305
00840 Fax Phone Number PROV9015
04230 Physician Assistants (PA) 0 PROV9020
00330 CBSA Urban Rural Indicator U SSAMSASZ
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