Basic Information
| Provider Information | |||||||||
| NPI: | 1982643169 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PENSACOLA PRIMARY CARE INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3 MARYLAND FARMS | ||||||||
| Address2: | SUITE 250 | ||||||||
| City: | BRENTWOOD | ||||||||
| State: | TN | ||||||||
| PostalCode: | 370275005 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8006613365 | ||||||||
| FaxNumber: | 8666894661 | ||||||||
| Practice Location | |||||||||
| Address1: | 2120 EAST JOHNSON AVENUE | ||||||||
| Address2: | SUITE 103 | ||||||||
| City: | PENSACOLA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 325146050 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8504943965 | ||||||||
| FaxNumber: | 8504943966 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/05/2006 | ||||||||
| LastUpdateDate: | 10/15/2008 | ||||||||
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| AuthorizedOfficialLastName: | PICKLER | ||||||||
| AuthorizedOfficialFirstName: | MICKEY | ||||||||
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| AuthorizedOfficialTitleorPosition: | VP | ||||||||
| AuthorizedOfficialTelephone: | 8505232117 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | 207Q00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 261180500 | 05 | FL | MEDICAID |