MEDICARE: FT. WALTON BEACH GENERAL SURGERY 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	208600000X	Surgery Physician

General Provider Information

NPI Number	:	1194769950
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FT. WALTON BEACH GENERAL SURGERY LLC

Provider Business Mailing Address
First Line	:	1775 LEWIS TURNER BLVD
Second Line	:	#102
City	:	FT WALTON BEACH
State	:	FL
Zip	:	32547-1221
Country	:	US
Telephone Number	:	850-864-3232
Fax Number	:

Provider Business Practice Location Address
First Line	:	1775 LEWIS TURNER BLVD
Second Line	:	#102
City	:	FT WALTON BEACH
State	:	FL
Zip	:	32547-1221
Country	:	US
Telephone Number	:	850-864-3232
Fax Number	:

Authorized Official
Title or Position	:	VP
Name	:	MICKEY PICKLER
Credential	:
Telephone Number	:	850-864-3232

Provider Enumeration Date	:	06/15/2006
Last Update Date	:	09/11/2007

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