MEDICARE: MR. CHARLES W. KUEBLER III P.A.

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	207P00000X	Emergency Medicine Physician	PA9100651	FL
2	363A00000X	Physician Assistant	PA9100651	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1932211356
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. CHARLES W. KUEBLER III P.A.

Provider Business Mailing Address
First Line	:	PO BOX 2699
Second Line	:	ATTN: SHMG/HPE
City	:	PENSACOLA
State	:	FL
Zip	:	32513-2699
Country	:	US
Telephone Number	:	850-278-3821
Fax Number	:	850-475-4781

Provider Business Practice Location Address
First Line	:	164 W HEWETT RD
Second Line	:
City	:	SANTA ROSA BEACH
State	:	FL
Zip	:	32459-3310
Country	:	US
Telephone Number	:	850-278-3821
Fax Number	:	850-475-4781

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/31/2006
Last Update Date	:	06/16/2016

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