MEDICARE: EHW PROFESSIONAL SERVICES, PLLC

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	261QU0200X	Urgent Care Clinic/Center

General Provider Information

NPI Number	:	1417263997
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EHW PROFESSIONAL SERVICES, PLLC

Provider Business Mailing Address
First Line	:	2208 PENTLAND RD
Second Line	:
City	:	LYNN HAVEN
State	:	FL
Zip	:	32444-5359
Country	:	US
Telephone Number	:	813-390-2203
Fax Number	:	850-248-2225

Provider Business Practice Location Address
First Line	:	109 W 23RD ST
Second Line	:	SUITE N 5
City	:	PANAMA CITY
State	:	FL
Zip	:	32405-7610
Country	:	US
Telephone Number	:	813-390-2203
Fax Number	:	850-248-2225

Authorized Official
Title or Position	:	MANAGER/OWNER
Name	:	MR. ROGER WAYNE HOLLEGER
Credential	:
Telephone Number	:	229-522-0535

Provider Enumeration Date	:	08/23/2010
Last Update Date	:	08/23/2010

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