1801294962 NPI number — DESTIN PULMONARY CRITICAL CARE, PLLC

Table of content: KYLE MILLER MS, ATC, GTS (NPI 1710685680)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1801294962 NPI number — DESTIN PULMONARY CRITICAL CARE, PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DESTIN PULMONARY CRITICAL CARE, PLLC
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:
1801294962
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/12/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
249 MACK BAYOU LOOP STE 201
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SANTA ROSA BEACH
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32459-7197
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
850-608-6288
Provider Business Mailing Address Fax Number:
850-608-6236

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
249 MACK BAYOU LOOP STE 201
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SANTA ROSA BEACH
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32459-7197
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
850-608-6288
Provider Business Practice Location Address Fax Number:
850-608-6236
Provider Enumeration Date:
12/05/2014

Additional Information

Authorized Official

Authorized Official Last Name:
YERBY
Authorized Official First Name:
PANDRA
Authorized Official Middle Name:
MAE
Authorized Official Title or Position:
BILLING SUPERVISOR
Authorized Official Telephone Number:
850-608-6288

Provider Taxonomy Codes

  • Taxonomy code: 207RP1001X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RC0200X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 014076700 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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