Basic Information
| Provider Information | |||||||||
| NPI: | 1184624660 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | AYCOCK | ||||||||
| FirstName: | GEORGE | ||||||||
| MiddleName: | R | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1717 N E ST | ||||||||
| Address2: | SUITE 331 | ||||||||
| City: | PENSACOLA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 325016339 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8504846500 | ||||||||
| FaxNumber: | 8508571747 | ||||||||
| Practice Location | |||||||||
| Address1: | 1717 N E ST | ||||||||
| Address2: | SUITE 331 | ||||||||
| City: | PENSACOLA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 32501 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8504846500 | ||||||||
| FaxNumber: | 8508571747 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/27/2005 | ||||||||
| LastUpdateDate: | 06/14/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/14/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X | 12442 | AL | N | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease | 207RC0000X | ME44213 | FL | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
| ID | Type | State | Issuer | Description | 0690937 00 | 05 | FL | MEDICAID | 110445 | 05 | AL | MEDICAID | 110310 | 05 | AL | MEDICAID | 009965180 | 05 | AL | MEDICAID | 110241 | 05 | AL | MEDICAID | 110312 | 05 | AL | MEDICAID | AA2781525 | 01 | FL | DEA | OTHER |