Basic Information
| Provider Information | |||||||||
| NPI: | 1134463482 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PANHANDLE ORTHOPAEDICS LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 710 HOSPITAL DR | ||||||||
| Address2: | |||||||||
| City: | CRESTVIEW | ||||||||
| State: | FL | ||||||||
| PostalCode: | 325397380 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8503988480 | ||||||||
| FaxNumber: | 8503988482 | ||||||||
| Practice Location | |||||||||
| Address1: | 12909 PANAMA CITY BEACH PKWY | ||||||||
| Address2: | |||||||||
| City: | PANAMA CITY BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 32407 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8507847724 | ||||||||
| FaxNumber: | 8507844711 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/26/2012 | ||||||||
| LastUpdateDate: | 08/23/2018 | ||||||||
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| AuthorizedOfficialLastName: | GILMORE | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
| AuthorizedOfficialMiddleName: | D | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT/OWNER | ||||||||
| AuthorizedOfficialTelephone: | 8503988480 | ||||||||
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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 | 2080S0010X | FL | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | Sports Medicine | 2081S0010X | FL | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation | Sports Medicine | 225100000X | FL | N | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 207XX0005X | FL | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Sports Medicine | 2251X0800X | FL | N | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Orthopedic | 225200000X | FL | N | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapy Assistant | 363A00000X | FL | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363AS0400X | FL | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical | 207X00000X | FL | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 004K2 | 01 | FL | BLUE CROSS BLUE SHIELD OF FLORIDA | OTHER |