1750536876 NPI number — MR. WILLIAM FITCH MONTFORT IV IDC

Table of content: MR. WILLIAM FITCH MONTFORT IV IDC (NPI 1750536876)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1750536876 NPI number — MR. WILLIAM FITCH MONTFORT IV IDC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MONTFORT
Provider First Name:
WILLIAM
Provider Middle Name:
FITCH
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
IV
Provider Credential Text:
IDC
Provider Gender Code:
M

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:
1750536876
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/18/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
101 VERNON AVE BLDG 89-A
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PANAMA CITY BEACH
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32407-7018
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
850-235-5092
Provider Business Mailing Address Fax Number:
850-230-7208

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
101 VERNON AVE BLDG 89-A
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PANAMA CITY BEACH
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32407-7018
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
850-235-5092
Provider Business Practice Location Address Fax Number:
850-230-7208
Provider Enumeration Date:
11/18/2008

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1710I1002X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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