Basic Information
Provider Information | |||||||||
NPI: | 1902857972 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | 4MD2 PHYSICIAN SERVICES OF NICEVILLE LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 88490 | ||||||||
Address2: |   | ||||||||
City: | CHICAGO | ||||||||
State: | IL | ||||||||
PostalCode: | 606801490 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2054376098 | ||||||||
FaxNumber: | 2054375998 | ||||||||
Practice Location | |||||||||
Address1: | 2190 HIGHWAY 85 N | ||||||||
Address2: |   | ||||||||
City: | NICEVILLE | ||||||||
State: | FL | ||||||||
PostalCode: | 325781045 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8507299490 | ||||||||
FaxNumber: | 2054375998 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/15/2006 | ||||||||
LastUpdateDate: | 07/20/2007 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | HOOPER | ||||||||
AuthorizedOfficialFirstName: | GUY | ||||||||
AuthorizedOfficialMiddleName: | DUWANE | ||||||||
AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
AuthorizedOfficialTelephone: | 2054376098 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X |   |   | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 2621276 | 01 | FL | UNITEDHEALTHCARE OF FL | OTHER | 97861 | 01 | FL | GROUP BCBS NUMBER | OTHER | 7946836 | 01 | FL | AETNA GROUP NO | OTHER | DE3244 | 01 | FL | GROUP RRMC NUMBER | OTHER | F952 | 01 | AL | BCBS GROUP NO | OTHER |