Basic Information
| Provider Information | |||||||||
| NPI: | 1740429679 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | NORTHWEST FLORIDA PRIMARY CARE LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2000 HEALTH PARK DR | ||||||||
| Address2: | |||||||||
| City: | BRENTWOOD | ||||||||
| State: | TN | ||||||||
| PostalCode: | 370274525 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6153725426 | ||||||||
| FaxNumber: | 8668314898 | ||||||||
| Practice Location | |||||||||
| Address1: | 4400 E HIGHWAY 20 STE 203 | ||||||||
| Address2: | |||||||||
| City: | NICEVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 325787700 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8508973678 | ||||||||
| FaxNumber: | 8508973708 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/17/2009 | ||||||||
| LastUpdateDate: | 11/10/2017 | ||||||||
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| AuthorizedOfficialLastName: | RODKEY | ||||||||
| AuthorizedOfficialFirstName: | JOHN | ||||||||
| AuthorizedOfficialMiddleName: | MARK | ||||||||
| AuthorizedOfficialTitleorPosition: | VICE PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 8505233816 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208M00000X | FL | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Hospitalist |
No ID Information.