Basic Information
| Provider Information | |||||||||
| NPI: | 1568436962 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | 325 MDG | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2405 MAPLE CT | ||||||||
| Address2: | |||||||||
| City: | PANAMA CITY | ||||||||
| State: | FL | ||||||||
| PostalCode: | 324043047 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8502837511 | ||||||||
| FaxNumber: | 8502837721 | ||||||||
| Practice Location | |||||||||
| Address1: | 325 MDG BLDG | ||||||||
| Address2: | 1305 SUWANNEE AVE | ||||||||
| City: | TYNDALL AFB | ||||||||
| State: | FL | ||||||||
| PostalCode: | 32403 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8502837511 | ||||||||
| FaxNumber: | 8502837721 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/14/2006 | ||||||||
| LastUpdateDate: | 06/13/2008 | ||||||||
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| AuthorizedOfficialLastName: | NICHOLAS | ||||||||
| AuthorizedOfficialFirstName: | GEORGE | ||||||||
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| AuthorizedOfficialTitleorPosition: | 325 MDG COMMANDER | ||||||||
| AuthorizedOfficialTelephone: | 8502837515 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | JR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | PY5848 | FL | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist |
No ID Information.