Healthcare Provider Details

I. General information

NPI: 1801213020
Provider Name (Legal Business Name): SOUTHLAND HOSPITLALIST AT CHIPLEY, PL.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/26/2014
Last Update Date: 09/07/2022
Certification Date: 09/07/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1360 BRICKYARD RD
CHIPLEY FL
32428-6303
US

IV. Provider business mailing address

PO BOX 5218
NICEVILLE FL
32578-5218
US

V. Phone/Fax

Practice location:
  • Phone: 850-638-1610
  • Fax:
Mailing address:
  • Phone: 850-897-7244
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number
License Number State

VIII. Authorized Official

Name: LINDA BELL
Title or Position: CFO
Credential:
Phone: 850-897-7244