MEDICARE: TALLAHASSEE GYN-ONCOLOGY 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	207VX0201X	Gynecologic Oncology Physician	ME96687	FL

General Provider Information

NPI Number	:	1750480380
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TALLAHASSEE GYN-ONCOLOGY LLC

Provider Business Mailing Address
First Line	:	PO BOX 100196
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30384-0196
Country	:	US
Telephone Number	:	808-780-5134
Fax Number	:	850-784-7706

Provider Business Practice Location Address
First Line	:	2770 CAPITAL MEDICAL BLVD
Second Line	:	SUITE 210
City	:	TALLAHASSEE
State	:	FL
Zip	:	32308-8417
Country	:	US
Telephone Number	:	850-877-7392
Fax Number	:	850-877-1535

Authorized Official
Title or Position	:	VICE PRESIDENT
Name	:	MR. MICKEY S PICKLER
Credential	:
Telephone Number	:	850-523-2117

Provider Enumeration Date	:	09/21/2006
Last Update Date	:	01/25/2008

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