POS Hospital Custom Report
Line
Line Description
Line Value
Type
POS Name
100001
SHANDS JACKSONVILLE
JACKSONVILLE, FL 32209
A
00090
Old Provider Number for this Provider
100170
CODE
PROV0300
00100
Current FMS Survey Date
DATE
PROV0500
00110
Official Survey Date
02/26/1991
DATE
PROV2740
00120
Eligibility for Medicare/Mediciad
Yes
PROV0455
00140
Intermediary/Carrier Servicing Provider
Blue Cross (Florida)
PROV0605
00150
Medicare/Medicaid Vendor Number
CODE
PROV0655
00160
Date Approved for Medicare/Medicaid
07/01/1966
DATE
PROV1565
00170
Date of Prior Change in Ownership
DATE
PROV1615
00180
Prior Intermediary Number
CODE
PROV1620
00190
Provider Number
100001
CODE
PROV1680
00200
Current Status of Record
Accepted
PROV1720
00290
Termination Date/Expriation Date
DATE
PROV4500
00370
Accreditation Effective Date
06/21/2003
DATE
PROV0000
00380
Accreditation Expiration Date
06/20/2006
DATE
PROV0005
00400
Beds - Total
696
BEDS
PROV0740
00410
Beds - Total Certified
696
BEDS
PROV0755
00550
Date of Validation Survey
02/26/1991
DATE
PROV0450
00690
Psychiatric Unit Beds
000
BEDS
PROV1690
00700
Psychiatric Unit Effective Date
DATE
PROV1695
00730
Psychiatric Unit Termination Date
DATE
PROV1710
00810
Rehabilitation Unit Beds
0
BEDS
PROV1730
00820
Rehabilitation unit Effective Date
DATE
PROV1735
00850
Rehabilitation Unit Termination Date
DATE
PROV1750
100002
BETHESDA MEMORIAL HOSPITAL
BOYNTON BEACH, FL 33435
A
00090
Old Provider Number for this Provider
CODE
PROV0300
00100
Current FMS Survey Date
DATE
PROV0500
00110
Official Survey Date
12/07/1994
DATE
PROV2740
00120
Eligibility for Medicare/Mediciad
Yes
PROV0455
00140
Intermediary/Carrier Servicing Provider
Blue Cross (Florida)
PROV0605
00150
Medicare/Medicaid Vendor Number
10140100
CODE
PROV0655
00160
Date Approved for Medicare/Medicaid
07/01/1966
DATE
PROV1565
00170
Date of Prior Change in Ownership
10/01/1984
DATE
PROV1615
00180
Prior Intermediary Number
CODE
PROV1620
00190
Provider Number
100002
CODE
PROV1680
00200
Current Status of Record
Accepted
PROV1720
00290
Termination Date/Expriation Date
DATE
PROV4500
00370
Accreditation Effective Date
06/24/2006
DATE
PROV0000
00380
Accreditation Expiration Date
06/23/2009
DATE
PROV0005
00400
Beds - Total
362
BEDS
PROV0740
00410
Beds - Total Certified
362
BEDS
PROV0755
00550
Date of Validation Survey
DATE
PROV0450
00690
Psychiatric Unit Beds
020
BEDS
PROV1690
00700
Psychiatric Unit Effective Date
10/01/1989
DATE
PROV1695
00730
Psychiatric Unit Termination Date
01/25/2000
DATE
PROV1710
00810
Rehabilitation Unit Beds
28
BEDS
PROV1730
00820
Rehabilitation unit Effective Date
10/01/2005
DATE
PROV1735
00850
Rehabilitation Unit Termination Date
DATE
PROV1750
100004
MADISON COUNTY MEMORIAL HOSPITAL
MADISON, FL 32340
00090
Old Provider Number for this Provider
101311
CODE
PROV0300
00100
Current FMS Survey Date
DATE
PROV0500
00110
Official Survey Date
12/30/2004
DATE
PROV2740
00120
Eligibility for Medicare/Mediciad
Yes
PROV0455
00140
Intermediary/Carrier Servicing Provider
Blue Cross (Florida)
PROV0605
00150
Medicare/Medicaid Vendor Number
10115000
CODE
PROV0655
00160
Date Approved for Medicare/Medicaid
07/01/1966
DATE
PROV1565
00170
Date of Prior Change in Ownership
01/01/1984
DATE
PROV1615
00180
Prior Intermediary Number
CODE
PROV1620
00190
Provider Number
100004
CODE
PROV1680
00200
Current Status of Record
Accepted
PROV1720
00290
Termination Date/Expriation Date
12/31/2005
DATE
PROV4500
00370
Accreditation Effective Date
DATE
PROV0000
00380
Accreditation Expiration Date
DATE
PROV0005
00400
Beds - Total
42
BEDS
PROV0740
00410
Beds - Total Certified
42
BEDS
PROV0755
00550
Date of Validation Survey
DATE
PROV0450
00690
Psychiatric Unit Beds
000
BEDS
PROV1690
00700
Psychiatric Unit Effective Date
DATE
PROV1695
00730
Psychiatric Unit Termination Date
DATE
PROV1710
00810
Rehabilitation Unit Beds
0
BEDS
PROV1730
00820
Rehabilitation unit Effective Date
DATE
PROV1735
00850
Rehabilitation Unit Termination Date
DATE
PROV1750
100005
POLK GENERAL HOSPITAL
BARTOW, FL 33830
00090
Old Provider Number for this Provider
CODE
PROV0300
00100
Current FMS Survey Date
DATE
PROV0500
00110
Official Survey Date
10/24/1989
DATE
PROV2740
00120
Eligibility for Medicare/Mediciad
No
PROV0455
00140
Intermediary/Carrier Servicing Provider
Blue Cross (Florida)
PROV0605
00150
Medicare/Medicaid Vendor Number
CODE
PROV0655
00160
Date Approved for Medicare/Medicaid
07/01/1966
DATE
PROV1565
00170
Date of Prior Change in Ownership
DATE
PROV1615
00180
Prior Intermediary Number
CODE
PROV1620
00190
Provider Number
100005
CODE
PROV1680
00200
Current Status of Record
Accepted
PROV1720
00290
Termination Date/Expriation Date
09/30/1995
DATE
PROV4500
00370
Accreditation Effective Date
05/20/1988
DATE
PROV0000
00380
Accreditation Expiration Date
05/19/1991
DATE
PROV0005
00400
Beds - Total
180
BEDS
PROV0740
00410
Beds - Total Certified
180
BEDS
PROV0755
00550
Date of Validation Survey
10/24/1989
DATE
PROV0450
00690
Psychiatric Unit Beds
030
BEDS
PROV1690
00700
Psychiatric Unit Effective Date
10/01/1983
DATE
PROV1695
00730
Psychiatric Unit Termination Date
10/01/1985
DATE
PROV1710
00810
Rehabilitation Unit Beds
0
BEDS
PROV1730
00820
Rehabilitation unit Effective Date
DATE
PROV1735
00850
Rehabilitation Unit Termination Date
DATE
PROV1750
100006
ORLANDO REGIONAL HEALTHCARE
ORLANDO, FL 32806
A
00090
Old Provider Number for this Provider
CODE
PROV0300
00100
Current FMS Survey Date
DATE
PROV0500
00110
Official Survey Date
09/25/2000
DATE
PROV2740
00120
Eligibility for Medicare/Mediciad
Yes
PROV0455
00140
Intermediary/Carrier Servicing Provider
Blue Cross (Florida)
PROV0605
00150
Medicare/Medicaid Vendor Number
10133800
CODE
PROV0655
00160
Date Approved for Medicare/Medicaid
10/01/1977
DATE
PROV1565
00170
Date of Prior Change in Ownership
DATE
PROV1615
00180
Prior Intermediary Number
CODE
PROV1620
00190
Provider Number
100006
CODE
PROV1680
00200
Current Status of Record
Accepted
PROV1720
00290
Termination Date/Expriation Date
DATE
PROV4500
00370
Accreditation Effective Date
10/01/2005
DATE
PROV0000
00380
Accreditation Expiration Date
10/01/2008
DATE
PROV0005
00400
Beds - Total
1600
BEDS
PROV0740
00410
Beds - Total Certified
1600
BEDS
PROV0755
00550
Date of Validation Survey
07/10/1990
DATE
PROV0450
00690
Psychiatric Unit Beds
064
BEDS
PROV1690
00700
Psychiatric Unit Effective Date
10/01/1987
DATE
PROV1695
00730
Psychiatric Unit Termination Date
DATE
PROV1710
00810
Rehabilitation Unit Beds
35
BEDS
PROV1730
00820
Rehabilitation unit Effective Date
10/01/1999
DATE
PROV1735
00850
Rehabilitation Unit Termination Date
DATE
PROV1750
100007
FLORIDA HOSPITAL
ORLANDO, FL 32803
A
00090
Old Provider Number for this Provider
100162
CODE
PROV0300
00100
Current FMS Survey Date
DATE
PROV0500
00110
Official Survey Date
06/19/1990
DATE
PROV2740
00120
Eligibility for Medicare/Mediciad
Yes
PROV0455
00140
Intermediary/Carrier Servicing Provider
Blue Cross (Florida)
PROV0605
00150
Medicare/Medicaid Vendor Number
10129001
CODE
PROV0655
00160
Date Approved for Medicare/Medicaid
07/01/1966
DATE
PROV1565
00170
Date of Prior Change in Ownership
DATE
PROV1615
00180
Prior Intermediary Number
CODE
PROV1620
00190
Provider Number
100007
CODE
PROV1680
00200
Current Status of Record
Accepted
PROV1720
00290
Termination Date/Expriation Date
DATE
PROV4500
00370
Accreditation Effective Date
07/19/2003
DATE
PROV0000
00380
Accreditation Expiration Date
07/18/2006
DATE
PROV0005
00400
Beds - Total
1828
BEDS
PROV0740
00410
Beds - Total Certified
1828
BEDS
PROV0755
00550
Date of Validation Survey
06/19/1990
DATE
PROV0450
00690
Psychiatric Unit Beds
075
BEDS
PROV1690
00700
Psychiatric Unit Effective Date
01/01/2003
DATE
PROV1695
00730
Psychiatric Unit Termination Date
DATE
PROV1710
00810
Rehabilitation Unit Beds
30
BEDS
PROV1730
00820
Rehabilitation unit Effective Date
01/01/2007
DATE
PROV1735
00850
Rehabilitation Unit Termination Date
DATE
PROV1750
100008
BAPTIST HOSPITAL OF MIAMI INC
MIAMI, FL 33176
A
00090
Old Provider Number for this Provider
CODE
PROV0300
00100
Current FMS Survey Date
DATE
PROV0500
00110
Official Survey Date
04/06/2000
DATE
PROV2740
00120
Eligibility for Medicare/Mediciad
Yes
PROV0455
00140
Intermediary/Carrier Servicing Provider
Blue Cross (Florida)
PROV0605
00150
Medicare/Medicaid Vendor Number
10035800
CODE
PROV0655
00160
Date Approved for Medicare/Medicaid
07/01/1966
DATE
PROV1565
00170
Date of Prior Change in Ownership
DATE
PROV1615
00180
Prior Intermediary Number
CODE
PROV1620
00190
Provider Number
100008
CODE
PROV1680
00200
Current Status of Record
Accepted
PROV1720
00290
Termination Date/Expriation Date
DATE
PROV4500
00370
Accreditation Effective Date
05/01/1999
DATE
PROV0000
00380
Accreditation Expiration Date
05/01/2002
DATE
PROV0005
00400
Beds - Total
577
BEDS
PROV0740
00410
Beds - Total Certified
577
BEDS
PROV0755
00550
Date of Validation Survey
04/06/2000
DATE
PROV0450
00690
Psychiatric Unit Beds
000
BEDS
PROV1690
00700
Psychiatric Unit Effective Date
DATE
PROV1695
00730
Psychiatric Unit Termination Date
DATE
PROV1710
00810
Rehabilitation Unit Beds
36
BEDS
PROV1730
00820
Rehabilitation unit Effective Date
09/30/1991
DATE
PROV1735
00850
Rehabilitation Unit Termination Date
DATE
PROV1750
100009
CEDARS MEDICAL CENTER
MIAMI, FL 33136
A
00090
Old Provider Number for this Provider
CODE
PROV0300
00100
Current FMS Survey Date
DATE
PROV0500
00110
Official Survey Date
07/21/2006
DATE
PROV2740
00120
Eligibility for Medicare/Mediciad
Yes
PROV0455
00140
Intermediary/Carrier Servicing Provider
Mutual of Omaha Insurance Company
PROV0605
00150
Medicare/Medicaid Vendor Number
10036600
CODE
PROV0655
00160
Date Approved for Medicare/Medicaid
07/01/1966
DATE
PROV1565
00170
Date of Prior Change in Ownership
02/16/1993
DATE
PROV1615
00180
Prior Intermediary Number
Blue Cross (Florida)
CODE
PROV1620
00190
Provider Number
100009
CODE
PROV1680
00200
Current Status of Record
Accepted
PROV1720
00290
Termination Date/Expriation Date
DATE
PROV4500
00370
Accreditation Effective Date
07/01/2004
DATE
PROV0000
00380
Accreditation Expiration Date
06/30/2007
DATE
PROV0005
00400
Beds - Total
560
BEDS
PROV0740
00410
Beds - Total Certified
560
BEDS
PROV0755
00550
Date of Validation Survey
06/29/2001
DATE
PROV0450
00690
Psychiatric Unit Beds
050
BEDS
PROV1690
00700
Psychiatric Unit Effective Date
10/01/1999
DATE
PROV1695
00730
Psychiatric Unit Termination Date
DATE
PROV1710
00810
Rehabilitation Unit Beds
0
BEDS
PROV1730
00820
Rehabilitation unit Effective Date
DATE
PROV1735
00850
Rehabilitation Unit Termination Date
DATE
PROV1750
3/24/2008
10:27:57PM
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