Basic Information
| Provider Information | |||||||||
| NPI: | 1821049867 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | 4MD2 IN PATIENT PHYSICIAN SERVICES OF FORT WALTON BEACH LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 88477 | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606801477 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2054376098 | ||||||||
| FaxNumber: | 2054375998 | ||||||||
| Practice Location | |||||||||
| Address1: | 1000 MAR WALT DR | ||||||||
| Address2: | SUITE 266 | ||||||||
| City: | FORT WALTON BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 325476708 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8508637607 | ||||||||
| FaxNumber: | 2054375998 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/15/2006 | ||||||||
| LastUpdateDate: | 07/20/2007 | ||||||||
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| AuthorizedOfficialLastName: | HOOPER | ||||||||
| AuthorizedOfficialFirstName: | GUY | ||||||||
| AuthorizedOfficialMiddleName: | DUWANE | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 2054376098 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208M00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Hospitalist |
ID Information
| ID | Type | State | Issuer | Description | 2625352 | 01 | FL | UNITEDHEALTHCARE GROUP NO | OTHER | 97919 | 01 | FL | GROUP BCBS NUMBER | OTHER | DE2953 | 01 | FL | GROUP RRMC NUMBER | OTHER | 7532779 | 01 | FL | AETNA GROUP NO | OTHER | G017 | 01 | AL | BCBS GROUP PROVIDER NO | OTHER |