1821049867 NPI number — 4MD2 IN PATIENT PHYSICIAN SERVICES OF FORT WALTON BEACH LLC

Table of content: (NPI 1821049867)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1821049867 NPI number — 4MD2 IN PATIENT PHYSICIAN SERVICES OF FORT WALTON BEACH LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
4MD2 IN PATIENT PHYSICIAN SERVICES OF FORT WALTON BEACH LLC
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:
1821049867
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/20/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 88477
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHICAGO
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60680-1477
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
205-437-6098
Provider Business Mailing Address Fax Number:
205-437-5998

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1000 MAR WALT DR
Provider Second Line Business Practice Location Address:
SUITE 266
Provider Business Practice Location Address City Name:
FORT WALTON BEACH
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32547-6708
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
850-863-7607
Provider Business Practice Location Address Fax Number:
205-437-5998
Provider Enumeration Date:
05/15/2006

Additional Information

Authorized Official

Authorized Official Last Name:
HOOPER
Authorized Official First Name:
GUY
Authorized Official Middle Name:
DUWANE
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
205-437-6098

Provider Taxonomy Codes

  • Taxonomy code: 208M00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 2625352 . This is a "UNITEDHEALTHCARE GROUP NO" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 97919 . This is a "GROUP BCBS NUMBER" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: DE2953 . This is a "GROUP RRMC NUMBER" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 7532779 . This is a "AETNA GROUP NO" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: G017 . This is a "BCBS GROUP PROVIDER NO" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".




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