1184761538 NPI number — WHITE-WILSON MEDICAL CENTER, P.A.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1184761538 NPI number — WHITE-WILSON MEDICAL CENTER, P.A.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WHITE-WILSON MEDICAL CENTER, P.A.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1184761538
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1005 MAR WALT DR
Provider Second Line Business Mailing Address:
BUSINESS OFFICE
Provider Business Mailing Address City Name:
FORT WALTON BEACH
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32547-6707
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
850-863-8105
Provider Business Mailing Address Fax Number:
850-863-8548

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
990 AIRPORT RD
Provider Second Line Business Practice Location Address:
PEDIATRIC DEPARTMENT
Provider Business Practice Location Address City Name:
DESTIN
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32541-2820
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
850-837-3848
Provider Business Practice Location Address Fax Number:
850-654-9581
Provider Enumeration Date:
02/01/2007

Additional Information

Authorized Official

Authorized Official Last Name:
RIGBY
Authorized Official First Name:
DOUGLAS
Authorized Official Middle Name:
W
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
850-863-8131

Provider Taxonomy Codes

  • Taxonomy code: 208000000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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