Basic Information
| Provider Information | |||||||||
| NPI: | 1689998940 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PANAMA CITY PULMONARY LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1005 MAR WALT DR | ||||||||
| Address2: | |||||||||
| City: | FORT WALTON BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 325476707 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8502430118 | ||||||||
| FaxNumber: | 8502430594 | ||||||||
| Practice Location | |||||||||
| Address1: | 1005 MAR WALT DRIVE | ||||||||
| Address2: | PULMONOLOGY DEPARTMENT | ||||||||
| City: | FORT WALTON BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 325476707 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8502430118 | ||||||||
| FaxNumber: | 8502430594 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/16/2010 | ||||||||
| LastUpdateDate: | 11/05/2018 | ||||||||
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| AuthorizedOfficialLastName: | NUNEZ | ||||||||
| AuthorizedOfficialFirstName: | ANGEL | ||||||||
| AuthorizedOfficialMiddleName: | ARTURO | ||||||||
| AuthorizedOfficialTitleorPosition: | PHYSICIAN | ||||||||
| AuthorizedOfficialTelephone: | 8502430118 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0200X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Critical Care Medicine | 207RS0012X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Sleep Medicine | 207RP1001X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Pulmonary Disease |
ID Information
| ID | Type | State | Issuer | Description | 259704700 | 05 | FL | MEDICAID |