MEDICARE: FREEPORT FAMILY MEDICINE 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	207Q00000X	Family Medicine Physician

General Provider Information

NPI Number	:	1477595858
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FREEPORT FAMILY MEDICINE LLC

Provider Business Mailing Address
First Line	:	1588 HIGHWAY 20 WEST
Second Line	:
City	:	FREEPORT
State	:	FL
Zip	:	32439
Country	:	US
Telephone Number	:	850-835-7050
Fax Number	:	850-835-7045

Provider Business Practice Location Address
First Line	:	1588 HIGHWAY 20 WEST
Second Line	:
City	:	FREEPORT
State	:	FL
Zip	:	32439
Country	:	US
Telephone Number	:	850-835-7050
Fax Number	:	850-835-7045

Authorized Official
Title or Position	:	VP
Name	:	MICKEY PICKLER
Credential	:
Telephone Number	:	850-897-3678

Provider Enumeration Date	:	06/12/2006
Last Update Date	:	01/25/2008

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Directions to “FREEPORT FAMILY MEDICINE LLC ” Practice Location

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