POS Hospital Reference Report
Line
Line Descriptions
Value
Type
POS Field
100002
BETHESDA MEMORIAL HOSPITAL
BOYNTON BEACH, FL 33435
A
Subtype of provider
Short Term
PROV0085
00010
Category of Provider/Supplier
Hospital
PROV0075
00020
Change of Ownership Counter
02
PROV0095
00030
Change of Ownership Date
DATE
PROV0100
00040
Provider has Correction Plan for Deficiencies
PROV0220
00060
Provider in Compliance with Correction Plan
In Compliance
PROV2715
00070
Provider County
490
PROV2695
00080
Old Provider Number for this Provider
CODE
PROV0300
00090
Current FMS Survey Date
DATE
PROV0500
00100
Official Survey Date
DATE
12/07/1994
PROV2740
00110
Eligibility for Medicare/Mediciad
Yes
PROV0455
00120
Intermediary/Carrier Servicing Provider
00090
PROV0605
00140
Medicare/Medicaid Vendor Number
CODE
10140100
PROV0655
00150
Date Approved for Medicare/Medicaid
DATE
07/01/1966
PROV1565
00160
Date of Prior Change in Ownership
DATE
10/01/1984
PROV1615
00170
Prior Intermediary Number
CODE
PROV1620
00180
Provider Number
CODE
100002
PROV1680
00190
Current Status of Record
Accepted
PROV1720
00200
CMS Regional Office for Provider
Atlanta
PROV1725
00210
Skeleton Record Indicator
N
PROV2045
00220
Provider State
FL
PROV3230
00230
SSA State Code
10
PROV2700
00240
State Region Code (in selected states)
LAN
PROV2710
00250
Provider Telephone Number
5617377733
PROV1605
00270
Termination Reason Code
Active
PROV4770
00280
Termination Date/Expriation Date
DATE
PROV4500
00290
Type of Action for Transmittal
Recertification
PROV2880
00300
Type of Control for Provider
Voluntary Non-Profit - Private
PROV2885
00310
Provider Zip Code
33435
PROV2905
00320
Provider FIPS State
12
FIPSTATE
00330
Provider FIPS County
12099
FIPCNTY
00340
SSA MSA Code
637
SSAMSACD
00350
SSA MSA Size Code
C
SSAMSASZ
00360
Accreditation Effective Date
DATE
06/24/2006
PROV0000
00370
Accreditation Expiration Date
DATE
06/23/2009
PROV0005
00380
Accreditation Indicator
JCAHO
PROV0010
00390
Beds - Total
BEDS
362
PROV0740
00400
Beds - Total Certified
BEDS
362
PROV0755
00410
Certified RN Anesthetists
FTES
2.00
PROV0760
00420
CLIA - Hospital Lab ID #1
CODE
10D0287808
PROV0130
00430
CLIA - Hospital Lab ID #2
CODE
10D0287809
PROV0135
00440
CLIA - Hospital Lab ID #3
CODE
PROV0140
00450
CLIA - Hospital Lab ID #4
CODE
PROV0145
00460
CLIA - Hospital Lab ID #4
CODE
PROV0150
00470
Compliance - Life Safety Code
CMPL
PROV0240
00480
Compliance - Scope of Service
CMPL
PROV0280
00490
Compliance - Technical Personnel
CMPL
PROV0285
00500
Compliance - 24Hr Registered Nurse
CMPL
PROV0290
00510
Current Survey Ever Accredited
Y
PROV3545
00520
Current Survey Ever Non-Accredited
N
PROV3555
00530
Current Survey Ever SwingBed
N
PROV3550
00540
Date of Validation Survey
DATE
PROV0450
00550
Dieticians
FTES
5.72
PROV0820
00560
Fiscal Year Ending Month/Day
0930
PROV0485
00570
Licensed Practical/Vocational Nurses
FTES
60.12
PROV0955
00580
Medical School Affiliation
No Affiliation
PROV0645
00590
Medical technologists (Lab)
FTES
0.00
PROV6290
00600
Compliance - Section 1861 Emergency Hospital
CMPL
PROV0670
00610
Nuclear Medicine Technicians
FTES
5.03
PROV6295
00620
Occupational Therapists
FTES
4.59
PROV1050
00630
Other Personnel
FTES
996.50
PROV1075
00640
Participation in Medicare/Medicaid Program
CMPL
Y
PROV1575
00650
Physical Therapists
FTES
9.18
PROV1125
00660
Physician Assistants
FTES
0.00
PROV1115
00670
Program Participation - Medicare/Medicaid
Medicare and Medicaid
PROV1670
00680
Psychiatric Unit Beds
BEDS
020
PROV1690
00690
Psychiatric Unit Effective Date
DATE
10/01/1989
PROV1695
00700
Psychiatric Unit Indicator
Y
PROV1700
00710
Psychiatric Unit Termination Code
Voluntary - Merger or Close
PROV1705
00720
Psychiatric Unit Termination Date
DATE
01/25/2000
PROV1710
00730
Psychologists
FTES
0.00
PROV6300
00740
Radiology Technicians (Diagnostics)
FTES
25.56
PROV6305
00750
Region Override #1 for Number of Beds
PROV1545
00760
Region Override #2 for Staffing
Y
PROV1550
00770
Region Override #3 for Nurse/Bed
PROV1555
00780
Registered Nurses
FTES
395.48
PROV1145
00790
Registered Pharmacists
FTES
15.89
PROV1100
00800
Rehabilitation Unit Beds
BEDS
28
PROV1730
00810
Rehabilitation unit Effective Date
DATE
10/01/2005
PROV1735
00820
Rehabilitation Unit Indicator
Y
PROV1740
00830
Rehabilitation Unit Termination Code
Active
PROV1745
00840
Rehabilitation Unit Termination Date
DATE
PROV1750
00850
Resident Program Approved-Am Dental Assc
Not Approved
PROV1805
00860
Resident Program Approved-Am Medical Assc
Not Approved
PROV1810
00870
Resident Program Approved-Am Osteopathic Assc
Not Approved
PROV1815
00880
Resident Program Approved-Other
Not Approved
PROV1820
00890
Residents (Physicians)
FTES
0.00
PROV1165
00900
Inhalation Therapist
FTES
16.39
PROV0950
00910
Service - Acute Renal Dialysis
SVCS
Provided by Staff
PROV2055
00920
Service - Alchol and/or Drug
SVCS
Not Provided
PROV2065
00930
Servide - Ambulance (Owned)
SVCS
Not Provided
PROV6155
00940
Service - Anesthesia
SVCS
Provided under Arrangement
PROV2070
00950
Service - Audiology
SVCS
Provided by Staff
PROV6160
00960
Service - Blood Bank
SVCS
Provided by Staff
PROV5675
00970
Service - Burn Care Unit
SVCS
Not Provided
PROV2090
00980
Service - Cardiac Catheterization Lab
SVCS
Provided by Staff
PROV6165
00990
Service - Open Heart Surgery Unit
SVCS
Not Provided
PROV2285
01000
Service - Chemotherapy Service
SVCS
Provided by Staff
PROV6170
01010
Service - Chiropractic
SVCS
Not Provided
PROV2100
01020
Service - CT Scanner
SVCS
Not Provided
PROV6175
01030
Service - Dental
SVCS
Not Provided
PROV2120
01040
Service - Dietary
SVCS
Provided by Staff
PROV2130
01050
Service - Emergency Department (Dedicated)
SVCS
Provided by Staff and Arrangement
PROV6180
01060
Service - Emergency Services (Organized)
SVCS
Provided by Staff and Arrangement
PROV2140
01070
Service - Gerotological Specialty
SVCS
Not Provided
PROV6190
01080
Service - Home Care Unit
SVCS
Provided by Staff
PROV2160
01090
Service - Hospice
SVCS
Provided under Arrangement
PROV2175
01100
Service - Coronary Care Unit
SVCS
Provided by Staff
PROV2110
01110
Service - Intensive Care Unit
SVCS
Provided by Staff
PROV2185
01120
Service - ICU Neonatal
SVCS
Provided by Staff
PROV6195
01130
Service - ICU Pediatric
SVCS
Provided by Staff
PROV6200
01140
Service - ICU Surgical
SVCS
Provided by Staff
PROV6205
01150
Service - Laboratory (Anatomical)
SVCS
Provided by Staff
PROV2205
01160
Service - Laboratory (clinical)
SVCS
Provided by Staff
PROV2210
01170
Service - Long Term Care Unit
SVCS
Not Provided
PROV2215
01180
Service - Magnetic Resonance Imaging
SVCS
Provided by Staff
PROV6210
01190
Service - Neonatal Nursery
SVCS
Provided by Staff
PROV2235
01200
Service - Neurosurgical Services
SVCS
Provided by Staff
PROV6215
01210
Service - Nuclear Medicine
SVCS
Provided by Staff
PROV2245
01220
Service - Obstetrics
SVCS
Provided by Staff
PROV2265
01230
Service - Occupational Therapy
SVCS
Provided by Staff
PROV2270
01240
Service - Operating Rooms
SVCS
Provided by Staff
PROV2300
01250
Service - Opthalmic Surgery
SVCS
Provided by Staff
PROV6220
01260
Service - Optometric Services
SVCS
Not Provided
PROV2295
01270
Service - Organ Bank
SVCS
Not Provided
PROV2310
01280
Service - Organ Transplant
SVCS
Not Provided
PROV2315
01290
Service - Orthopedic Surgery
SVCS
Provided by Staff
PROV6225
01300
Service - Outpatient
SVCS
Provided by Staff
PROV2350
01310
Service - Outpatient Surgery Unit
SVCS
Provided by Staff
PROV2355
01320
Service - Pediatric
SVCS
Provided by Staff
PROV2360
01330
Service - PET Scan Service
SVCS
Not Provided
PROV6230
01340
Service - Pharmacy
SVCS
Provided by Staff
PROV2365
01350
Service - Physicial Therapy
SVCS
Provided by Staff
PROV2370
01360
Service - Postoperative Recovery Room
SVCS
Provided by Staff
PROV2410
01370
Service - Psychiatric
SVCS
Provided by Staff
PROV2415
01380
Service - Psychiatric - Forensic
SVCS
Not Provided
PROV6245
01390
Service - Psychiatric - Geriatric
SVCS
Not Provided
PROV6250
01400
Service - Psychiatric - Outpatient
SVCS
Not Provided
PROV6255
01410
Service - Psychiatric - Child/Adolescent
SVCS
Not Provided
PROV6240
01420
Service - Psychiatric - Emergency
SVCS
Not Provided
PROV6235
01430
Service - Radiology (Diagnostic)
SVCS
Provided by Staff
PROV2440
01440
Service - Radiology (Therapeutic)
SVCS
Provided by Staff
PROV2445
01450
Service - Reconstructive Surgery
SVCS
Provided by Staff
PROV6260
01460
Service - Rehabilitation Inpatient (CARF)
SVCS
Not Provided
PROV6270
01470
Service - Rehabilitation Outpatient
SVCS
Not Provided
PROV6265
01480
Service - Rehabilitation
SVCS
Provided by Staff
PROV2450
01490
Service - Shock Wave Lithotripter
SVCS
Provided under Arrangement
PROV6185
01500
Service - Social Services
SVCS
Provided by Staff
PROV2485
01510
Service - Speech Pathology
SVCS
Provided by Staff
PROV2505
01520
Service - Inpatient Surgical
SVCS
Provided by Staff
PROV2190
01530
Servide - Transplant Center for Medicare
SVCS
Not Provided
PROV6275
01540
Service - Shock/Trauma
SVCS
Not Provided
PROV2475
01550
Service - Urgent Care Center Services
SVCS
Not Provided
PROV6280
01560
Swing Bed Indicator - Hospital/Long Term Care
Swing Bed service not approved
PROV2795
01570
Swing Bed Size Code
PROV2800
01580
Type of Facility
Short - Term
PROV2890
01590
Type of Non-Participating Provider
PROV0690
01600
Related Provider Number
CODE
PROV1755
02560
Speech Pathologists & Audiologists
FTES
1.00
PROV1220
03520
Physicians Employed by Provider
FTES
0.00
PROV1110
03920
Service - Respiratory Care
SVCS
Provided by Staff
PROV2455
04100
Medical Social Workers
FTES
1.00
PROV0975
04430
100080
JFK MEDICAL CENTER
ATLANTIS, FL 33462
A
Subtype of provider
Short Term
PROV0085
00010
Category of Provider/Supplier
Hospital
PROV0075
00020
Change of Ownership Counter
02
PROV0095
00030
Change of Ownership Date
DATE
PROV0100
00040
Provider has Correction Plan for Deficiencies
PROV0220
00060
Provider in Compliance with Correction Plan
Not In Compliance
PROV2715
00070
Provider County
490
PROV2695
00080
Old Provider Number for this Provider
CODE
PROV0300
00090
Current FMS Survey Date
DATE
PROV0500
00100
Official Survey Date
DATE
10/12/2000
PROV2740
00110
Eligibility for Medicare/Mediciad
Yes
PROV0455
00120
Intermediary/Carrier Servicing Provider
52280
PROV0605
00140
Medicare/Medicaid Vendor Number
CODE
10146000
PROV0655
00150
Date Approved for Medicare/Medicaid
DATE
07/01/1966
PROV1565
00160
Date of Prior Change in Ownership
DATE
07/15/1995
PROV1615
00170
Prior Intermediary Number
CODE
00090
PROV1620
00180
Provider Number
CODE
100080
PROV1680
00190
Current Status of Record
Accepted
PROV1720
00200
CMS Regional Office for Provider
Atlanta
PROV1725
00210
Skeleton Record Indicator
N
PROV2045
00220
Provider State
FL
PROV3230
00230
SSA State Code
10
PROV2700
00240
State Region Code (in selected states)
LAN
PROV2710
00250
Provider Telephone Number
5619657300
PROV1605
00270
Termination Reason Code
Active
PROV4770
00280
Termination Date/Expriation Date
DATE
PROV4500
00290
Type of Action for Transmittal
Validation (Accredited Hospital)
PROV2880
00300
Type of Control for Provider
Voluntary Non-Profit - Private
PROV2885
00310
Provider Zip Code
33462
PROV2905
00320
Provider FIPS State
12
FIPSTATE
00330
Provider FIPS County
12099
FIPCNTY
00340
SSA MSA Code
637
SSAMSACD
00350
SSA MSA Size Code
C
SSAMSASZ
00360
Accreditation Effective Date
DATE
11/18/2006
PROV0000
00370
Accreditation Expiration Date
DATE
11/17/2009
PROV0005
00380
Accreditation Indicator
JCAHO
PROV0010
00390
Beds - Total
BEDS
424
PROV0740
00400
Beds - Total Certified
BEDS
424
PROV0755
00410
Certified RN Anesthetists
FTES
1.00
PROV0760
00420
CLIA - Hospital Lab ID #1
CODE
PROV0130
00430
CLIA - Hospital Lab ID #2
CODE
PROV0135
00440
CLIA - Hospital Lab ID #3
CODE
PROV0140
00450
CLIA - Hospital Lab ID #4
CODE
PROV0145
00460
CLIA - Hospital Lab ID #4
CODE
PROV0150
00470
Compliance - Life Safety Code
CMPL
PROV0240
00480
Compliance - Scope of Service
CMPL
PROV0280
00490
Compliance - Technical Personnel
CMPL
PROV0285
00500
Compliance - 24Hr Registered Nurse
CMPL
PROV0290
00510
Current Survey Ever Accredited
Y
PROV3545
00520
Current Survey Ever Non-Accredited
N
PROV3555
00530
Current Survey Ever SwingBed
N
PROV3550
00540
Date of Validation Survey
DATE
10/12/2000
PROV0450
00550
Dieticians
FTES
0.50
PROV0820
00560
Fiscal Year Ending Month/Day
1231
PROV0485
00570
Licensed Practical/Vocational Nurses
FTES
10.60
PROV0955
00580
Medical School Affiliation
Limited
PROV0645
00590
Medical technologists (Lab)
FTES
0.00
PROV6290
00600
Compliance - Section 1861 Emergency Hospital
CMPL
PROV0670
00610
Nuclear Medicine Technicians
FTES
0.00
PROV6295
00620
Occupational Therapists
FTES
1.10
PROV1050
00630
Other Personnel
FTES
713.88
PROV1075
00640
Participation in Medicare/Medicaid Program
CMPL
Y
PROV1575
00650
Physical Therapists
FTES
5.00
PROV1125
00660
Physician Assistants
FTES
0.00
PROV1115
00670
Program Participation - Medicare/Medicaid
Medicare and Medicaid
PROV1670
00680
Psychiatric Unit Beds
BEDS
000
PROV1690
00690
Psychiatric Unit Effective Date
DATE
PROV1695
00700
Psychiatric Unit Indicator
PROV1700
00710
Psychiatric Unit Termination Code
PROV1705
00720
Psychiatric Unit Termination Date
DATE
PROV1710
00730
Psychologists
FTES
0.00
PROV6300
00740
Radiology Technicians (Diagnostics)
FTES
0.00
PROV6305
00750
Region Override #1 for Number of Beds
PROV1545
00760
Region Override #2 for Staffing
PROV1550
00770
Region Override #3 for Nurse/Bed
PROV1555
00780
Registered Nurses
FTES
400.53
PROV1145
00790
Registered Pharmacists
FTES
17.88
PROV1100
00800
Rehabilitation Unit Beds
BEDS
0
PROV1730
00810
Rehabilitation unit Effective Date
DATE
PROV1735
00820
Rehabilitation Unit Indicator
PROV1740
00830
Rehabilitation Unit Termination Code
PROV1745
00840
Rehabilitation Unit Termination Date
DATE
PROV1750
00850
Resident Program Approved-Am Dental Assc
Not Approved
PROV1805
00860
Resident Program Approved-Am Medical Assc
Not Approved
PROV1810
00870
Resident Program Approved-Am Osteopathic Assc
Not Approved
PROV1815
00880
Resident Program Approved-Other
Approved
PROV1820
00890
Residents (Physicians)
FTES
3.00
PROV1165
00900
Inhalation Therapist
FTES
0.26
PROV0950
00910
Service - Acute Renal Dialysis
SVCS
Provided under Arrangement
PROV2055
00920
Service - Alchol and/or Drug
SVCS
Not Provided
PROV2065
00930
Servide - Ambulance (Owned)
SVCS
Not Provided
PROV6155
00940
Service - Anesthesia
SVCS
Provided by Staff
PROV2070
00950
Service - Audiology
SVCS
Not Provided
PROV6160
00960
Service - Blood Bank
SVCS
Provided by Staff
PROV5675
00970
Service - Burn Care Unit
SVCS
Not Provided
PROV2090
00980
Service - Cardiac Catheterization Lab
SVCS
Not Provided
PROV6165
00990
Service - Open Heart Surgery Unit
SVCS
Provided by Staff
PROV2285
01000
Service - Chemotherapy Service
SVCS
Not Provided
PROV6170
01010
Service - Chiropractic
SVCS
Not Provided
PROV2100
01020
Service - CT Scanner
SVCS
Not Provided
PROV6175
01030
Service - Dental
SVCS
Not Provided
PROV2120
01040
Service - Dietary
SVCS
Provided by Staff
PROV2130
01050
Service - Emergency Department (Dedicated)
SVCS
Not Provided
PROV6180
01060
Service - Emergency Services (Organized)
SVCS
Provided by Staff
PROV2140
01070
Service - Gerotological Specialty
SVCS
Not Provided
PROV6190
01080
Service - Home Care Unit
SVCS
Not Provided
PROV2160
01090
Service - Hospice
SVCS
Provided under Arrangement
PROV2175
01100
Service - Coronary Care Unit
SVCS
Provided by Staff
PROV2110
01110
Service - Intensive Care Unit
SVCS
Provided by Staff
PROV2185
01120
Service - ICU Neonatal
SVCS
Not Provided
PROV6195
01130
Service - ICU Pediatric
SVCS
Not Provided
PROV6200
01140
Service - ICU Surgical
SVCS
Not Provided
PROV6205
01150
Service - Laboratory (Anatomical)
SVCS
Provided by Staff
PROV2205
01160
Service - Laboratory (clinical)
SVCS
Provided by Staff
PROV2210
01170
Service - Long Term Care Unit
SVCS
Not Provided
PROV2215
01180
Service - Magnetic Resonance Imaging
SVCS
Not Provided
PROV6210
01190
Service - Neonatal Nursery
SVCS
Not Provided
PROV2235
01200
Service - Neurosurgical Services
SVCS
Not Provided
PROV6215
01210
Service - Nuclear Medicine
SVCS
Provided by Staff
PROV2245
01220
Service - Obstetrics
SVCS
Not Provided
PROV2265
01230
Service - Occupational Therapy
SVCS
Provided by Staff
PROV2270
01240
Service - Operating Rooms
SVCS
Provided by Staff
PROV2300
01250
Service - Opthalmic Surgery
SVCS
Not Provided
PROV6220
01260
Service - Optometric Services
SVCS
Not Provided
PROV2295
01270
Service - Organ Bank
SVCS
Not Provided
PROV2310
01280
Service - Organ Transplant
SVCS
Not Provided
PROV2315
01290
Service - Orthopedic Surgery
SVCS
Not Provided
PROV6225
01300
Service - Outpatient
SVCS
Provided by Staff
PROV2350
01310
Service - Outpatient Surgery Unit
SVCS
Provided by Staff
PROV2355
01320
Service - Pediatric
SVCS
Not Provided
PROV2360
01330
Service - PET Scan Service
SVCS
Not Provided
PROV6230
01340
Service - Pharmacy
SVCS
Provided by Staff
PROV2365
01350
Service - Physicial Therapy
SVCS
Provided by Staff
PROV2370
01360
Service - Postoperative Recovery Room
SVCS
Provided by Staff
PROV2410
01370
Service - Psychiatric
SVCS
Not Provided
PROV2415
01380
Service - Psychiatric - Forensic
SVCS
Not Provided
PROV6245
01390
Service - Psychiatric - Geriatric
SVCS
Not Provided
PROV6250
01400
Service - Psychiatric - Outpatient
SVCS
Not Provided
PROV6255
01410
Service - Psychiatric - Child/Adolescent
SVCS
Not Provided
PROV6240
01420
Service - Psychiatric - Emergency
SVCS
Not Provided
PROV6235
01430
Service - Radiology (Diagnostic)
SVCS
Provided by Staff
PROV2440
01440
Service - Radiology (Therapeutic)
SVCS
Not Provided
PROV2445
01450
Service - Reconstructive Surgery
SVCS
Not Provided
PROV6260
01460
Service - Rehabilitation Inpatient (CARF)
SVCS
Not Provided
PROV6270
01470
Service - Rehabilitation Outpatient
SVCS
Not Provided
PROV6265
01480
Service - Rehabilitation
SVCS
Provided by Staff
PROV2450
01490
Service - Shock Wave Lithotripter
SVCS
Not Provided
PROV6185
01500
Service - Social Services
SVCS
Provided by Staff
PROV2485
01510
Service - Speech Pathology
SVCS
Provided by Staff
PROV2505
01520
Service - Inpatient Surgical
SVCS
Provided by Staff
PROV2190
01530
Servide - Transplant Center for Medicare
SVCS
Not Provided
PROV6275
01540
Service - Shock/Trauma
SVCS
Not Provided
PROV2475
01550
Service - Urgent Care Center Services
SVCS
Not Provided
PROV6280
01560
Swing Bed Indicator - Hospital/Long Term Care
Swing Bed service not approved
PROV2795
01570
Swing Bed Size Code
PROV2800
01580
Type of Facility
Short - Term
PROV2890
01590
Type of Non-Participating Provider
PROV0690
01600
Related Provider Number
CODE
PROV1755
02560
Speech Pathologists & Audiologists
FTES
0.80
PROV1220
03520
Physicians Employed by Provider
FTES
0.00
PROV1110
03920
Service - Respiratory Care
SVCS
Provided by Staff
PROV2455
04100
Medical Social Workers
FTES
2.00
PROV0975
04430
100130
GLADES GENERAL HOSPITAL
BELLE GLADE, FL 33430
A
Subtype of provider
Short Term
PROV0085
00010
Category of Provider/Supplier
Hospital
PROV0075
00020
Change of Ownership Counter
03
PROV0095
00030
Change of Ownership Date
DATE
04/30/2004
PROV0100
00040
Provider has Correction Plan for Deficiencies
PROV0220
00060
Provider in Compliance with Correction Plan
In Compliance
PROV2715
00070
Provider County
490
PROV2695
00080
Old Provider Number for this Provider
CODE
PROV0300
00090
Current FMS Survey Date
DATE
PROV0500
00100
Official Survey Date
DATE
05/08/1992
PROV2740
00110
Eligibility for Medicare/Mediciad
Yes
PROV0455
00120
Intermediary/Carrier Servicing Provider
00090
PROV0605
00140
Medicare/Medicaid Vendor Number
CODE
PROV0655
00150
Date Approved for Medicare/Medicaid
DATE
07/01/1966
PROV1565
00160
Date of Prior Change in Ownership
DATE
04/12/1999
PROV1615
00170
Prior Intermediary Number
CODE
PROV1620
00180
Provider Number
CODE
100130
PROV1680
00190
Current Status of Record
Accepted
PROV1720
00200
CMS Regional Office for Provider
Atlanta
PROV1725
00210
Skeleton Record Indicator
PROV2045
00220
Provider State
FL
PROV3230
00230
SSA State Code
10
PROV2700
00240
State Region Code (in selected states)
LAN
PROV2710
00250
Provider Telephone Number
5616597144
PROV1605
00270
Termination Reason Code
Active
PROV4770
00280
Termination Date/Expriation Date
DATE
PROV4500
00290
Type of Action for Transmittal
Recertification
PROV2880
00300
Type of Control for Provider
Government - Local
PROV2885
00310
Provider Zip Code
33430
PROV2905
00320
Provider FIPS State
12
FIPSTATE
00330
Provider FIPS County
12099
FIPCNTY
00340
SSA MSA Code
637
SSAMSACD
00350
SSA MSA Size Code
C
SSAMSASZ
00360
Accreditation Effective Date
DATE
03/20/2004
PROV0000
00370
Accreditation Expiration Date
DATE
03/20/2007
PROV0005
00380
Accreditation Indicator
JCAHO
PROV0010
00390
Beds - Total
BEDS
73
PROV0740
00400
Beds - Total Certified
BEDS
73
PROV0755
00410
Certified RN Anesthetists
FTES
0.00
PROV0760
00420
CLIA - Hospital Lab ID #1
CODE
10D0287388
PROV0130
00430
CLIA - Hospital Lab ID #2
CODE
PROV0135
00440
CLIA - Hospital Lab ID #3
CODE
PROV0140
00450
CLIA - Hospital Lab ID #4
CODE
PROV0145
00460
CLIA - Hospital Lab ID #4
CODE
PROV0150
00470
Compliance - Life Safety Code
CMPL
PROV0240
00480
Compliance - Scope of Service
CMPL
PROV0280
00490
Compliance - Technical Personnel
CMPL
PROV0285
00500
Compliance - 24Hr Registered Nurse
CMPL
PROV0290
00510
Current Survey Ever Accredited
Y
PROV3545
00520
Current Survey Ever Non-Accredited
N
PROV3555
00530
Current Survey Ever SwingBed
N
PROV3550
00540
Date of Validation Survey
DATE
PROV0450
00550
Dieticians
FTES
0.50
PROV0820
00560
Fiscal Year Ending Month/Day
0930
PROV0485
00570
Licensed Practical/Vocational Nurses
FTES
16.00
PROV0955
00580
Medical School Affiliation
No Affiliation
PROV0645
00590
Medical technologists (Lab)
FTES
0.00
PROV6290
00600
Compliance - Section 1861 Emergency Hospital
CMPL
PROV0670
00610
Nuclear Medicine Technicians
FTES
0.00
PROV6295
00620
Occupational Therapists
FTES
0.00
PROV1050
00630
Other Personnel
FTES
166.30
PROV1075
00640
Participation in Medicare/Medicaid Program
CMPL
Y
PROV1575
00650
Physical Therapists
FTES
0.00
PROV1125
00660
Physician Assistants
FTES
0.00
PROV1115
00670
Program Participation - Medicare/Medicaid
Medicare and Medicaid
PROV1670
00680
Psychiatric Unit Beds
BEDS
000
PROV1690
00690
Psychiatric Unit Effective Date
DATE
PROV1695
00700
Psychiatric Unit Indicator
PROV1700
00710
Psychiatric Unit Termination Code
PROV1705
00720
Psychiatric Unit Termination Date
DATE
PROV1710
00730
Psychologists
FTES
0.00
PROV6300
00740
Radiology Technicians (Diagnostics)
FTES
0.00
PROV6305
00750
Region Override #1 for Number of Beds
PROV1545
00760
Region Override #2 for Staffing
PROV1550
00770
Region Override #3 for Nurse/Bed
PROV1555
00780
Registered Nurses
FTES
86.00
PROV1145
00790
Registered Pharmacists
FTES
1.50
PROV1100
00800
Rehabilitation Unit Beds
BEDS
0
PROV1730
00810
Rehabilitation unit Effective Date
DATE
PROV1735
00820
Rehabilitation Unit Indicator
PROV1740
00830
Rehabilitation Unit Termination Code
PROV1745
00840
Rehabilitation Unit Termination Date
DATE
PROV1750
00850
Resident Program Approved-Am Dental Assc
Not Approved
PROV1805
00860
Resident Program Approved-Am Medical Assc
Not Approved
PROV1810
00870
Resident Program Approved-Am Osteopathic Assc
Not Approved
PROV1815
00880
Resident Program Approved-Other
Not Approved
PROV1820
00890
Residents (Physicians)
FTES
0.00
PROV1165
00900
Inhalation Therapist
FTES
0.00
PROV0950
00910
Service - Acute Renal Dialysis
SVCS
Provided under Arrangement
PROV2055
00920
Service - Alchol and/or Drug
SVCS
Not Provided
PROV2065
00930
Servide - Ambulance (Owned)
SVCS
Not Provided
PROV6155
00940
Service - Anesthesia
SVCS
Provided under Arrangement
PROV2070
00950
Service - Audiology
SVCS
Not Provided
PROV6160
00960
Service - Blood Bank
SVCS
Provided under Arrangement
PROV5675
00970
Service - Burn Care Unit
SVCS
Not Provided
PROV2090
00980
Service - Cardiac Catheterization Lab
SVCS
Not Provided
PROV6165
00990
Service - Open Heart Surgery Unit
SVCS
Not Provided
PROV2285
01000
Service - Chemotherapy Service
SVCS
Not Provided
PROV6170
01010
Service - Chiropractic
SVCS
Not Provided
PROV2100
01020
Service - CT Scanner
SVCS
Not Provided
PROV6175
01030
Service - Dental
SVCS
Not Provided
PROV2120
01040
Service - Dietary
SVCS
Provided by Staff
PROV2130
01050
Service - Emergency Department (Dedicated)
SVCS
Not Provided
PROV6180
01060
Service - Emergency Services (Organized)
SVCS
Provided by Staff and Arrangement
PROV2140
01070
Service - Gerotological Specialty
SVCS
Not Provided
PROV6190
01080
Service - Home Care Unit
SVCS
Not Provided
PROV2160
01090
Service - Hospice
SVCS
Not Provided
PROV2175
01100
Service - Coronary Care Unit
SVCS
Not Provided
PROV2110
01110
Service - Intensive Care Unit
SVCS
Provided by Staff
PROV2185
01120
Service - ICU Neonatal
SVCS
Not Provided
PROV6195
01130
Service - ICU Pediatric
SVCS
Not Provided
PROV6200
01140
Service - ICU Surgical
SVCS
Not Provided
PROV6205
01150
Service - Laboratory (Anatomical)
SVCS
Provided under Arrangement
PROV2205
01160
Service - Laboratory (clinical)
SVCS
Provided by Staff
PROV2210
01170
Service - Long Term Care Unit
SVCS
Not Provided
PROV2215
01180
Service - Magnetic Resonance Imaging
SVCS
Not Provided
PROV6210
01190
Service - Neonatal Nursery
SVCS
Not Provided
PROV2235
01200
Service - Neurosurgical Services
SVCS
Not Provided
PROV6215
01210
Service - Nuclear Medicine
SVCS
Provided by Staff
PROV2245
01220
Service - Obstetrics
SVCS
Provided by Staff
PROV2265
01230
Service - Occupational Therapy
SVCS
Not Provided
PROV2270
01240
Service - Operating Rooms
SVCS
Provided by Staff
PROV2300
01250
Service - Opthalmic Surgery
SVCS
Not Provided
PROV6220
01260
Service - Optometric Services
SVCS
Not Provided
PROV2295
01270
Service - Organ Bank
SVCS
Not Provided
PROV2310
01280
Service - Organ Transplant
SVCS
Not Provided
PROV2315
01290
Service - Orthopedic Surgery
SVCS
Not Provided
PROV6225
01300
Service - Outpatient
SVCS
Provided by Staff
PROV2350
01310
Service - Outpatient Surgery Unit
SVCS
Not Provided
PROV2355
01320
Service - Pediatric
SVCS
Provided by Staff
PROV2360
01330
Service - PET Scan Service
SVCS
Not Provided
PROV6230
01340
Service - Pharmacy
SVCS
Provided by Staff
PROV2365
01350
Service - Physicial Therapy
SVCS
Provided under Arrangement
PROV2370
01360
Service - Postoperative Recovery Room
SVCS
Not Provided
PROV2410
01370
Service - Psychiatric
SVCS
Not Provided
PROV2415
01380
Service - Psychiatric - Forensic
SVCS
Not Provided
PROV6245
01390
Service - Psychiatric - Geriatric
SVCS
Not Provided
PROV6250
01400
Service - Psychiatric - Outpatient
SVCS
Not Provided
PROV6255
01410
Service - Psychiatric - Child/Adolescent
SVCS
Not Provided
PROV6240
01420
Service - Psychiatric - Emergency
SVCS
Not Provided
PROV6235
01430
Service - Radiology (Diagnostic)
SVCS
Provided by Staff
PROV2440
01440
Service - Radiology (Therapeutic)
SVCS
Not Provided
PROV2445
01450
Service - Reconstructive Surgery
SVCS
Not Provided
PROV6260
01460
Service - Rehabilitation Inpatient (CARF)
SVCS
Not Provided
PROV6270
01470
Service - Rehabilitation Outpatient
SVCS
Not Provided
PROV6265
01480
Service - Rehabilitation
SVCS
Not Provided
PROV2450
01490
Service - Shock Wave Lithotripter
SVCS
Not Provided
PROV6185
01500
Service - Social Services
SVCS
Not Provided
PROV2485
01510
Service - Speech Pathology
SVCS
Not Provided
PROV2505
01520
Service - Inpatient Surgical
SVCS
Provided by Staff
PROV2190
01530
Servide - Transplant Center for Medicare
SVCS
Not Provided
PROV6275
01540
Service - Shock/Trauma
SVCS
Not Provided
PROV2475
01550
Service - Urgent Care Center Services
SVCS
Not Provided
PROV6280
01560
Swing Bed Indicator - Hospital/Long Term Care
Swing Bed service not approved
PROV2795
01570
Swing Bed Size Code
PROV2800
01580
Type of Facility
Short - Term
PROV2890
01590
Type of Non-Participating Provider
PROV0690
01600
Related Provider Number
CODE
PROV1755
02560
Speech Pathologists & Audiologists
FTES
0.00
PROV1220
03520
Physicians Employed by Provider
FTES
3.00
PROV1110
03920
Service - Respiratory Care
SVCS
Provided under Arrangement
PROV2455
04100
Medical Social Workers
FTES
0.00
PROV0975
04430
100168
BOCA RATON COMMUNITY HOSPITAL INC
BOCA RATON, FL 33486
A
Subtype of provider
Short Term
PROV0085
00010
Category of Provider/Supplier
Hospital
PROV0075
00020
Change of Ownership Counter
00
PROV0095
00030
Change of Ownership Date
DATE
PROV0100
00040
Provider has Correction Plan for Deficiencies
PROV0220
00060
Provider in Compliance with Correction Plan
In Compliance
PROV2715
00070
Provider County
490
PROV2695
00080
Old Provider Number for this Provider
CODE
PROV0300
00090
Current FMS Survey Date
DATE
PROV0500
00100
Official Survey Date
DATE
10/20/1992
PROV2740
00110
Eligibility for Medicare/Mediciad
Yes
PROV0455
00120
Intermediary/Carrier Servicing Provider
00090
PROV0605
00140
Medicare/Medicaid Vendor Number
CODE
10141900
PROV0655
00150
Date Approved for Medicare/Medicaid
DATE
07/27/1967
PROV1565
00160
Date of Prior Change in Ownership
DATE
PROV1615
00170
Prior Intermediary Number
CODE
PROV1620
00180
Provider Number
CODE
100168
PROV1680
00190
Current Status of Record
Accepted
PROV1720
00200
CMS Regional Office for Provider
Atlanta
PROV1725
00210
Skeleton Record Indicator
N
PROV2045
00220
Provider State
FL
PROV3230
00230
SSA State Code
10
PROV2700
00240
State Region Code (in selected states)
LAN
PROV2710
00250
Provider Telephone Number
5613625002
PROV1605
00270
Termination Reason Code
Active
PROV4770
00280
Termination Date/Expriation Date
DATE
PROV4500
00290
Type of Action for Transmittal
Recertification
PROV2880
00300
Type of Control for Provider
Voluntary Non-Profit - Private
PROV2885
00310
Provider Zip Code
33486
PROV2905
00320
Provider FIPS State
12
FIPSTATE
00330
Provider FIPS County
12099
FIPCNTY
00340
SSA MSA Code
637
SSAMSACD
00350
SSA MSA Size Code
C
SSAMSASZ
00360
Accreditation Effective Date
DATE
07/29/2006
PROV0000
00370
Accreditation Expiration Date
DATE
07/28/2009
PROV0005
00380
Accreditation Indicator
JCAHO
PROV0010
00390
Beds - Total
BEDS
400
PROV0740
00400
Beds - Total Certified
BEDS
400
PROV0755
00410
Certified RN Anesthetists
FTES
0.00
PROV0760
00420
CLIA - Hospital Lab ID #1
CODE
PROV0130
00430
CLIA - Hospital Lab ID #2
CODE
PROV0135
00440
CLIA - Hospital Lab ID #3
CODE
PROV0140
00450
CLIA - Hospital Lab ID #4
CODE
PROV0145
00460
CLIA - Hospital Lab ID #4
CODE
PROV0150
00470
Compliance - Life Safety Code
CMPL
PROV0240
00480
Compliance - Scope of Service
CMPL
PROV0280
00490
Compliance - Technical Personnel
CMPL
PROV0285
00500
Compliance - 24Hr Registered Nurse
CMPL
PROV0290
00510
Current Survey Ever Accredited
Y
PROV3545
00520
Current Survey Ever Non-Accredited
N
PROV3555
00530
Current Survey Ever SwingBed
N
PROV3550
00540
Date of Validation Survey
DATE
09/06/1989
PROV0450
00550
Dieticians
FTES
6.00
PROV0820
00560
Fiscal Year Ending Month/Day
0630
PROV0485
00570
Licensed Practical/Vocational Nurses
FTES
27.50
PROV0955
00580
Medical School Affiliation
No Affiliation
PROV0645
00590
Medical technologists (Lab)
FTES
0.00
PROV6290
00600
Compliance - Section 1861 Emergency Hospital
CMPL
PROV0670
00610
Nuclear Medicine Technicians
FTES
0.00
PROV6295
00620
Occupational Therapists
FTES
3.00
PROV1050
00630
Other Personnel
FTES
1045.00
PROV1075
00640
Participation in Medicare/Medicaid Program
CMPL
Y
PROV1575
00650
Physical Therapists
FTES
17.00
PROV1125
00660
Physician Assistants
FTES
0.00
PROV1115
00670
Program Participation - Medicare/Medicaid
Medicare and Medicaid
PROV1670
00680
Psychiatric Unit Beds
BEDS
000
PROV1690
00690
Psychiatric Unit Effective Date
DATE
PROV1695
00700
Psychiatric Unit Indicator
PROV1700
00710
Psychiatric Unit Termination Code
PROV1705
00720
Psychiatric Unit Termination Date
DATE
PROV1710
00730
Psychologists
FTES
0.00
PROV6300
00740
Radiology Technicians (Diagnostics)
FTES
0.00
PROV6305
00750
Region Override #1 for Number of Beds
PROV1545
00760
Region Override #2 for Staffing
PROV1550
00770
Region Override #3 for Nurse/Bed
PROV1555
00780
Registered Nurses
FTES
404.00
PROV1145
00790
Registered Pharmacists
FTES
17.50
PROV1100
00800
Rehabilitation Unit Beds
BEDS
0
PROV1730
00810
Rehabilitation unit Effective Date
DATE
PROV1735
00820
Rehabilitation Unit Indicator
PROV1740
00830
Rehabilitation Unit Termination Code
PROV1745
00840
Rehabilitation Unit Termination Date
DATE
PROV1750
00850
Resident Program Approved-Am Dental Assc
Not Approved
PROV1805
00860
Resident Program Approved-Am Medical Assc
Not Approved
PROV1810
00870
Resident Program Approved-Am Osteopathic Assc
Not Approved
PROV1815
00880
Resident Program Approved-Other
Not Approved
PROV1820
00890
Residents (Physicians)
FTES
0.00
PROV1165
00900
Inhalation Therapist
FTES
16.50
PROV0950
00910
Service - Acute Renal Dialysis
SVCS
Provided by Staff
PROV2055
00920
Service - Alchol and/or Drug
SVCS
Not Provided
PROV2065
00930
Servide - Ambulance (Owned)
SVCS
Not Provided
PROV6155
00940
Service - Anesthesia
SVCS
Provided by Staff
PROV2070
00950
Service - Audiology
SVCS
Not Provided
PROV6160
00960
Service - Blood Bank
SVCS
Provided by Staff
PROV5675
00970
Service - Burn Care Unit
SVCS
Not Provided
PROV2090
00980
Service - Cardiac Catheterization Lab
SVCS
Not Provided
PROV6165
00990
Service - Open Heart Surgery Unit
SVCS
Not Provided
PROV2285
01000
Service - Chemotherapy Service
SVCS
Not Provided
PROV6170
01010
Service - Chiropractic
SVCS
Not Provided
PROV2100
01020
Service - CT Scanner
SVCS
Not Provided
PROV6175
01030
Service - Dental
SVCS
Not Provided
PROV2120
01040
Service - Dietary
SVCS
Provided by Staff
PROV2130
01050
Service - Emergency Department (Dedicated)
SVCS
Not Provided
PROV6180
01060
Service - Emergency Services (Organized)
SVCS
Provided by Staff
PROV2140
01070
Service - Gerotological Specialty
SVCS
Not Provided
PROV6190
01080
Service - Home Care Unit
SVCS
Provided by Staff
PROV2160
01090
Service - Hospice
SVCS
Not Provided
PROV2175
01100
Service - Coronary Care Unit
SVCS
Provided by Staff
PROV2110
01110
Service - Intensive Care Unit
SVCS
Provided by Staff
PROV2185
01120
Service - ICU Neonatal
SVCS
Not Provided
PROV6195
01130
Service - ICU Pediatric
SVCS
Not Provided
PROV6200
01140
Service - ICU Surgical
SVCS
Not Provided
PROV6205
01150
Service - Laboratory (Anatomical)
SVCS
Provided by Staff
PROV2205
01160
Service - Laboratory (clinical)
SVCS
Provided by Staff
PROV2210
01170
Service - Long Term Care Unit
SVCS
Not Provided
PROV2215
01180
Service - Magnetic Resonance Imaging
SVCS
Not Provided
PROV6210
01190
Service - Neonatal Nursery
SVCS
Not Provided
PROV2235
01200
Service - Neurosurgical Services
SVCS
Not Provided
PROV6215
01210
Service - Nuclear Medicine
SVCS
Provided by Staff
PROV2245
01220
Service - Obstetrics
SVCS
Not Provided
PROV2265
01230
Service - Occupational Therapy
SVCS
Provided by Staff
PROV2270
01240
Service - Operating Rooms
SVCS
Provided by Staff
PROV2300
01250
Service - Opthalmic Surgery
SVCS
Not Provided
PROV6220
01260
Service - Optometric Services
SVCS
Not Provided
PROV2295
01270
Service - Organ Bank
SVCS
Not Provided
PROV2310
01280
Service - Organ Transplant
SVCS
Not Provided
PROV2315
01290
Service - Orthopedic Surgery
SVCS
Not Provided
PROV6225
01300
Service - Outpatient
SVCS
Provided by Staff
PROV2350
01310
Service - Outpatient Surgery Unit
SVCS
Provided by Staff
PROV2355
01320
Service - Pediatric
SVCS
Provided by Staff
PROV2360
01330
Service - PET Scan Service
SVCS
Not Provided
PROV6230
01340
Service - Pharmacy
SVCS
Provided by Staff
PROV2365
01350
Service - Physicial Therapy
SVCS
Provided by Staff
PROV2370
01360
Service - Postoperative Recovery Room
SVCS
Provided by Staff
PROV2410
01370
Service - Psychiatric
SVCS
Provided by Staff
PROV2415
01380
Service - Psychiatric - Forensic
SVCS
Not Provided
PROV6245
01390
Service - Psychiatric - Geriatric
SVCS
Not Provided
PROV6250
01400
Service - Psychiatric - Outpatient
SVCS
Not Provided
PROV6255
01410
Service - Psychiatric - Child/Adolescent
SVCS
Not Provided
PROV6240
01420
Service - Psychiatric - Emergency
SVCS
Not Provided
PROV6235
01430
Service - Radiology (Diagnostic)
SVCS
Provided by Staff
PROV2440
01440
Service - Radiology (Therapeutic)
SVCS
Provided by Staff
PROV2445
01450
Service - Reconstructive Surgery
SVCS
Not Provided
PROV6260
01460
Service - Rehabilitation Inpatient (CARF)
SVCS
Not Provided
PROV6270
01470
Service - Rehabilitation Outpatient
SVCS
Not Provided
PROV6265
01480
Service - Rehabilitation
SVCS
Provided by Staff
PROV2450
01490
Service - Shock Wave Lithotripter
SVCS
Not Provided
PROV6185
01500
Service - Social Services
SVCS
Provided by Staff
PROV2485
01510
Service - Speech Pathology
SVCS
Provided by Staff
PROV2505
01520
Service - Inpatient Surgical
SVCS
Provided by Staff
PROV2190
01530
Servide - Transplant Center for Medicare
SVCS
Not Provided
PROV6275
01540
Service - Shock/Trauma
SVCS
Not Provided
PROV2475
01550
Service - Urgent Care Center Services
SVCS
Not Provided
PROV6280
01560
Swing Bed Indicator - Hospital/Long Term Care
Swing Bed service not approved
PROV2795
01570
Swing Bed Size Code
PROV2800
01580
Type of Facility
Short - Term
PROV2890
01590
Type of Non-Participating Provider
PROV0690
01600
Related Provider Number
CODE
PROV1755
02560
Speech Pathologists & Audiologists
FTES
4.00
PROV1220
03520
Physicians Employed by Provider
FTES
0.00
PROV1110
03920
Service - Respiratory Care
SVCS
Provided by Staff
PROV2455
04100
Medical Social Workers
FTES
4.50
PROV0975
04430
100176
PALM BEACH GARDENS MEDICAL CENTER
PALM BEACH GARDENS, FL 33410
A
Subtype of provider
Short Term
PROV0085
00010
Category of Provider/Supplier
Hospital
PROV0075
00020
Change of Ownership Counter
00
PROV0095
00030
Change of Ownership Date
DATE
PROV0100
00040
Provider has Correction Plan for Deficiencies
PROV0220
00060
Provider in Compliance with Correction Plan
In Compliance
PROV2715
00070
Provider County
490
PROV2695
00080
Old Provider Number for this Provider
CODE
PROV0300
00090
Current FMS Survey Date
DATE
10/11/2002
PROV0500
00100
Official Survey Date
DATE
12/05/1994
PROV2740
00110
Eligibility for Medicare/Mediciad
Yes
PROV0455
00120
Intermediary/Carrier Servicing Provider
52280
PROV0605
00140
Medicare/Medicaid Vendor Number
CODE
10210500
PROV0655
00150
Date Approved for Medicare/Medicaid
DATE
12/14/1970
PROV1565
00160
Date of Prior Change in Ownership
DATE
PROV1615
00170
Prior Intermediary Number
CODE
00090
PROV1620
00180
Provider Number
CODE
100176
PROV1680
00190
Current Status of Record
Accepted
PROV1720
00200
CMS Regional Office for Provider
Atlanta
PROV1725
00210
Skeleton Record Indicator
N
PROV2045
00220
Provider State
FL
PROV3230
00230
SSA State Code
10
PROV2700
00240
State Region Code (in selected states)
LAN
PROV2710
00250
Provider Telephone Number
5616221411
PROV1605
00270
Termination Reason Code
Active
PROV4770
00280
Termination Date/Expriation Date
DATE
PROV4500
00290
Type of Action for Transmittal
Recertification
PROV2880
00300
Type of Control for Provider
Proprietary
PROV2885
00310
Provider Zip Code
33410
PROV2905
00320
Provider FIPS State
12
FIPSTATE
00330
Provider FIPS County
12099
FIPCNTY
00340
SSA MSA Code
637
SSAMSACD
00350
SSA MSA Size Code
C
SSAMSASZ
00360
Accreditation Effective Date
DATE
08/12/2006
PROV0000
00370
Accreditation Expiration Date
DATE
08/11/2009
PROV0005
00380
Accreditation Indicator
JCAHO
PROV0010
00390
Beds - Total
BEDS
204
PROV0740
00400
Beds - Total Certified
BEDS
204
PROV0755
00410
Certified RN Anesthetists
FTES
0.00
PROV0760
00420
CLIA - Hospital Lab ID #1
CODE
10D0287016
PROV0130
00430
CLIA - Hospital Lab ID #2
CODE
PROV0135
00440
CLIA - Hospital Lab ID #3
CODE
PROV0140
00450
CLIA - Hospital Lab ID #4
CODE
PROV0145
00460
CLIA - Hospital Lab ID #4
CODE
PROV0150
00470
Compliance - Life Safety Code
CMPL
PROV0240
00480
Compliance - Scope of Service
CMPL
PROV0280
00490
Compliance - Technical Personnel
CMPL
PROV0285
00500
Compliance - 24Hr Registered Nurse
CMPL
PROV0290
00510
Current Survey Ever Accredited
Y
PROV3545
00520
Current Survey Ever Non-Accredited
N
PROV3555
00530
Current Survey Ever SwingBed
N
PROV3550
00540
Date of Validation Survey
DATE
09/05/1989
PROV0450
00550
Dieticians
FTES
4.50
PROV0820
00560
Fiscal Year Ending Month/Day
1231
PROV0485
00570
Licensed Practical/Vocational Nurses
FTES
22.00
PROV0955
00580
Medical School Affiliation
No Affiliation
PROV0645
00590
Medical technologists (Lab)
FTES
0.00
PROV6290
00600
Compliance - Section 1861 Emergency Hospital
CMPL
PROV0670
00610
Nuclear Medicine Technicians
FTES
0.00
PROV6295
00620
Occupational Therapists
FTES
0.00
PROV1050
00630
Other Personnel
FTES
336.50
PROV1075
00640
Participation in Medicare/Medicaid Program
CMPL
Y
PROV1575
00650
Physical Therapists
FTES
5.00
PROV1125
00660
Physician Assistants
FTES
0.00
PROV1115
00670
Program Participation - Medicare/Medicaid
Medicare and Medicaid
PROV1670
00680
Psychiatric Unit Beds
BEDS
000
PROV1690
00690
Psychiatric Unit Effective Date
DATE
PROV1695
00700
Psychiatric Unit Indicator
PROV1700
00710
Psychiatric Unit Termination Code
PROV1705
00720
Psychiatric Unit Termination Date
DATE
PROV1710
00730
Psychologists
FTES
0.00
PROV6300
00740
Radiology Technicians (Diagnostics)
FTES
0.00
PROV6305
00750
Region Override #1 for Number of Beds
PROV1545
00760
Region Override #2 for Staffing
PROV1550
00770
Region Override #3 for Nurse/Bed
PROV1555
00780
Registered Nurses
FTES
227.00
PROV1145
00790
Registered Pharmacists
FTES
7.00
PROV1100
00800
Rehabilitation Unit Beds
BEDS
0
PROV1730
00810
Rehabilitation unit Effective Date
DATE
PROV1735
00820
Rehabilitation Unit Indicator
PROV1740
00830
Rehabilitation Unit Termination Code
PROV1745
00840
Rehabilitation Unit Termination Date
DATE
PROV1750
00850
Resident Program Approved-Am Dental Assc
Not Approved
PROV1805
00860
Resident Program Approved-Am Medical Assc
Not Approved
PROV1810
00870
Resident Program Approved-Am Osteopathic Assc
Not Approved
PROV1815
00880
Resident Program Approved-Other
Not Approved
PROV1820
00890
Residents (Physicians)
FTES
0.00
PROV1165
00900
Inhalation Therapist
FTES
19.00
PROV0950
00910
Service - Acute Renal Dialysis
SVCS
Provided under Arrangement
PROV2055
00920
Service - Alchol and/or Drug
SVCS
Not Provided
PROV2065
00930
Servide - Ambulance (Owned)
SVCS
Not Provided
PROV6155
00940
Service - Anesthesia
SVCS
Provided under Arrangement
PROV2070
00950
Service - Audiology
SVCS
Not Provided
PROV6160
00960
Service - Blood Bank
SVCS
Provided by Staff
PROV5675
00970
Service - Burn Care Unit
SVCS
Not Provided
PROV2090
00980
Service - Cardiac Catheterization Lab
SVCS
Not Provided
PROV6165
00990
Service - Open Heart Surgery Unit
SVCS
Provided by Staff
PROV2285
01000
Service - Chemotherapy Service
SVCS
Not Provided
PROV6170
01010
Service - Chiropractic
SVCS
Not Provided
PROV2100
01020
Service - CT Scanner
SVCS
Not Provided
PROV6175
01030
Service - Dental
SVCS
Not Provided
PROV2120
01040
Service - Dietary
SVCS
Provided by Staff
PROV2130
01050
Service - Emergency Department (Dedicated)
SVCS
Not Provided
PROV6180
01060
Service - Emergency Services (Organized)
SVCS
Provided by Staff and Arrangement
PROV2140
01070
Service - Gerotological Specialty
SVCS
Not Provided
PROV6190
01080
Service - Home Care Unit
SVCS
Provided under Arrangement
PROV2160
01090
Service - Hospice
SVCS
Provided under Arrangement
PROV2175
01100
Service - Coronary Care Unit
SVCS
Provided by Staff
PROV2110
01110
Service - Intensive Care Unit
SVCS
Provided by Staff
PROV2185
01120
Service - ICU Neonatal
SVCS
Not Provided
PROV6195
01130
Service - ICU Pediatric
SVCS
Not Provided
PROV6200
01140
Service - ICU Surgical
SVCS
Not Provided
PROV6205
01150
Service - Laboratory (Anatomical)
SVCS
Provided by Staff
PROV2205
01160
Service - Laboratory (clinical)
SVCS
Provided by Staff
PROV2210
01170
Service - Long Term Care Unit
SVCS
Not Provided
PROV2215
01180
Service - Magnetic Resonance Imaging
SVCS
Not Provided
PROV6210
01190
Service - Neonatal Nursery
SVCS
Provided by Staff
PROV2235
01200
Service - Neurosurgical Services
SVCS
Not Provided
PROV6215
01210
Service - Nuclear Medicine
SVCS
Provided by Staff
PROV2245
01220
Service - Obstetrics
SVCS
Provided by Staff
PROV2265
01230
Service - Occupational Therapy
SVCS
Provided under Arrangement
PROV2270
01240
Service - Operating Rooms
SVCS
Provided by Staff
PROV2300
01250
Service - Opthalmic Surgery
SVCS
Not Provided
PROV6220
01260
Service - Optometric Services
SVCS
Not Provided
PROV2295
01270
Service - Organ Bank
SVCS
Not Provided
PROV2310
01280
Service - Organ Transplant
SVCS
Not Provided
PROV2315
01290
Service - Orthopedic Surgery
SVCS
Not Provided
PROV6225
01300
Service - Outpatient
SVCS
Provided by Staff
PROV2350
01310
Service - Outpatient Surgery Unit
SVCS
Provided by Staff
PROV2355
01320
Service - Pediatric
SVCS
Provided by Staff
PROV2360
01330
Service - PET Scan Service
SVCS
Not Provided
PROV6230
01340
Service - Pharmacy
SVCS
Provided by Staff
PROV2365
01350
Service - Physicial Therapy
SVCS
Provided by Staff
PROV2370
01360
Service - Postoperative Recovery Room
SVCS
Provided by Staff
PROV2410
01370
Service - Psychiatric
SVCS
Not Provided
PROV2415
01380
Service - Psychiatric - Forensic
SVCS
Not Provided
PROV6245
01390
Service - Psychiatric - Geriatric
SVCS
Not Provided
PROV6250
01400
Service - Psychiatric - Outpatient
SVCS
Not Provided
PROV6255
01410
Service - Psychiatric - Child/Adolescent
SVCS
Not Provided
PROV6240
01420
Service - Psychiatric - Emergency
SVCS
Not Provided
PROV6235
01430
Service - Radiology (Diagnostic)
SVCS
Provided by Staff
PROV2440
01440
Service - Radiology (Therapeutic)
SVCS
Provided by Staff
PROV2445
01450
Service - Reconstructive Surgery
SVCS
Not Provided
PROV6260
01460
Service - Rehabilitation Inpatient (CARF)
SVCS
Not Provided
PROV6270
01470
Service - Rehabilitation Outpatient
SVCS
Not Provided
PROV6265
01480
Service - Rehabilitation
SVCS
Not Provided
PROV2450
01490
Service - Shock Wave Lithotripter
SVCS
Not Provided
PROV6185
01500
Service - Social Services
SVCS
Provided by Staff
PROV2485
01510
Service - Speech Pathology
SVCS
Provided under Arrangement
PROV2505
01520
Service - Inpatient Surgical
SVCS
Provided by Staff
PROV2190
01530
Servide - Transplant Center for Medicare
SVCS
Not Provided
PROV6275
01540
Service - Shock/Trauma
SVCS
Not Provided
PROV2475
01550
Service - Urgent Care Center Services
SVCS
Not Provided
PROV6280
01560
Swing Bed Indicator - Hospital/Long Term Care
Swing Bed service not approved
PROV2795
01570
Swing Bed Size Code
PROV2800
01580
Type of Facility
Short - Term
PROV2890
01590
Type of Non-Participating Provider
PROV0690
01600
Related Provider Number
CODE
PROV1755
02560
Speech Pathologists & Audiologists
FTES
0.00
PROV1220
03520
Physicians Employed by Provider
FTES
0.00
PROV1110
03920
Service - Respiratory Care
SVCS
Provided by Staff
PROV2455
04100
Medical Social Workers
FTES
3.00
PROV0975
04430
6/10/2008
11:44:53AM
C
:
\
DOCUME
~
1
\
ROBERT
~
1
\
LOCALS
~
1
\
Temp
\
temp
_
ebb
98138
-
3
a
9
a
-
4700
-
95
c
9
-
a
05
b
36
dcc
1
a
3
{
41
F
47
DC
5
-
0
E
2
C
-
404
E
-
A
481
-
59
CFD
1987
EDB
}
.
rpt
Page 16 of 16
11:44 am
www
.
halmanac
.
com
6/10/2008
Healthcare Almanac
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561
)
228
-
1582