Basic Information
| Provider Information | |||||||||
| NPI: | 1184140683 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LIVE OAK NEUROSURGICAL ASSOCIATES PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2243 | ||||||||
| Address2: | |||||||||
| City: | PENSACOLA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 325132243 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8504781312 | ||||||||
| FaxNumber: | 8504749060 | ||||||||
| Practice Location | |||||||||
| Address1: | 8333 N DAVIS HWY FL 10 | ||||||||
| Address2: | |||||||||
| City: | PENSACOLA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 32514 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8505123482 | ||||||||
| FaxNumber: | 8509692130 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/16/2017 | ||||||||
| LastUpdateDate: | 10/31/2018 | ||||||||
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| AuthorizedOfficialLastName: | WOLFF | ||||||||
| AuthorizedOfficialFirstName: | CHARLES | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 8508907706 | ||||||||
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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 | 207T00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Neurological Surgery |
ID Information
| ID | Type | State | Issuer | Description | 022217200 | 05 | FL | MEDICAID | QYYRS | 01 | FL | FLORIDA BLUE | OTHER |