Basic Information
| Provider Information | |||||||||
| NPI: | 1043652498 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MAR-WALT DRIVE EMERGENCY PHYSICIANS, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 815 S PALAFOX ST | ||||||||
| Address2: | STE 300 | ||||||||
| City: | PENSACOLA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 325025960 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8004447009 | ||||||||
| FaxNumber: | 8003053233 | ||||||||
| Practice Location | |||||||||
| Address1: | 1000 MAR WALT DR | ||||||||
| Address2: | |||||||||
| City: | FORT WALTON BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 325476708 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8508637610 | ||||||||
| FaxNumber: | 8003053233 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/26/2013 | ||||||||
| LastUpdateDate: | 07/26/2013 | ||||||||
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| AuthorizedOfficialLastName: | GATEWOOD | ||||||||
| AuthorizedOfficialFirstName: | JOSEPH | ||||||||
| AuthorizedOfficialMiddleName: | H. | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 8004447009 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207PP0204X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine | Pediatric Emergency Medicine | 207P00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine |
No ID Information.