Basic Information
Provider Information | |||||||||
NPI: | 1790912269 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | NORTHWEST FLORIDA MULTISPECIALTY PHYSICIANS LLC | ||||||||
LastName: |   | ||||||||
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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: | 1032 MAR WALT DR | ||||||||
Address2: | SUITE 250 | ||||||||
City: | FORT WALTON BEACH | ||||||||
State: | FL | ||||||||
PostalCode: | 325476661 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8508633463 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/11/2009 | ||||||||
LastUpdateDate: | 11/10/2017 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | RODKEY | ||||||||
AuthorizedOfficialFirstName: | JOHN | ||||||||
AuthorizedOfficialMiddleName: | MARK | ||||||||
AuthorizedOfficialTitleorPosition: | VICE PRESIDENT | ||||||||
AuthorizedOfficialTelephone: | 8505233816 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207T00000X |   |   | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Neurological Surgery |   |
No ID Information.