MEDICARE: THOMAS J. DERBES, M.D., LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2084N0400X	Neurology Physician	ME48177	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	26046	OTHER	FL	BLUE CROSS

General Provider Information

NPI Number	:	1033573720
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	THOMAS J. DERBES, M.D., LLC

Provider Business Mailing Address
First Line	:	100 DOCTORS DR
Second Line	:	SUITE B
City	:	PANAMA CITY
State	:	FL
Zip	:	32405-7608
Country	:	US
Telephone Number	:	850-872-1300
Fax Number	:	850-872-9420

Provider Business Practice Location Address
First Line	:	100 DOCTORS DR
Second Line	:	SUITE B
City	:	PANAMA CITY
State	:	FL
Zip	:	32405-7608
Country	:	US
Telephone Number	:	850-872-1300
Fax Number	:	850-872-1300

Authorized Official
Title or Position	:	ADM
Name	:	MRS. BRENDA BURNS
Credential	:
Telephone Number	:	850-872-1300

Provider Enumeration Date	:	04/08/2016
Last Update Date	:	04/08/2016

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