1659541340 NPI number — SOUTH WALTON MEDICAL CENTER INC

Table of content: KRISTINA PECK (NPI 1023773595)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1659541340 NPI number — SOUTH WALTON MEDICAL CENTER INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SOUTH WALTON MEDICAL CENTER INC
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:
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:
1659541340
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/03/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
10005C US HIGHWAY 98 W
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DESTIN
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32550-4962
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
850-837-8005
Provider Business Mailing Address Fax Number:
850-837-4352

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10005C US HIGHWAY 98 W
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DESTIN
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32550-4962
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
850-837-8005
Provider Business Practice Location Address Fax Number:
850-837-4352
Provider Enumeration Date:
03/10/2008

Additional Information

Authorized Official

Authorized Official Last Name:
CAUSTON
Authorized Official First Name:
RONALD
Authorized Official Middle Name:
BRUCE
Authorized Official Title or Position:
OWNER/PHYSICIAN
Authorized Official Telephone Number:
850-837-8005

Provider Taxonomy Codes

  • Taxonomy code: 261Q00000X , with the licence number:  FLME43330 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 265468700 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 46168 . This is a "BC BS" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".




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