Healthcare Provider Details

I. General information

NPI: 1467188953
Provider Name (Legal Business Name): MTM SPECIALIST
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/27/2022
Last Update Date: 03/08/2023
Certification Date: 03/08/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

123 J HARVEY ETHRIDGE ST
BONIFAY FL
32425-2104
US

IV. Provider business mailing address

1423 CONSERVANCY DR E
TALLAHASSEE FL
32312-6772
US

V. Phone/Fax

Practice location:
  • Phone: 850-591-9694
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code3336C0002X
TaxonomyClinic Pharmacy
License Number
License Number StateNULL

VIII. Authorized Official

Name: DR. MARK BYINGTON
Title or Position: MANAGER
Credential:
Phone: 850-591-9694