Basic Information
| Provider Information | |||||||||
| NPI: | 1053606988 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | HEALTHSTAT PENSACOLA LLC | ||||||||
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| OtherOrganizationName: | HEALTHSTAT ON-SITE CLINIC | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4601 CHARLOTTE PARK DR | ||||||||
| Address2: | SUITE 390 | ||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282171915 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7045296161 | ||||||||
| FaxNumber: | 7049365570 | ||||||||
| Practice Location | |||||||||
| Address1: | 1678 AIRPORT BLVD | ||||||||
| Address2: | |||||||||
| City: | PENSACOLA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 325048618 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8504793790 | ||||||||
| FaxNumber: | 8504793920 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/20/2011 | ||||||||
| LastUpdateDate: | 10/04/2011 | ||||||||
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| AuthorizedOfficialLastName: | KINZLER | ||||||||
| AuthorizedOfficialFirstName: | SUSAN | ||||||||
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| AuthorizedOfficialTitleorPosition: | EVP SALES & MARKETING | ||||||||
| AuthorizedOfficialTelephone: | 7045296161 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 5706657 | 01 | NCPDP PROVIDER IDENTIFICATION NUMBER | OTHER |