Healthcare Provider Details

I. General information

NPI: 1144458621
Provider Name (Legal Business Name): PANHANDLE SURGICAL INSTITUTE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/23/2009
Last Update Date: 06/23/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

710 HOSPITAL DR
CRESTVIEW FL
32539-7380
US

IV. Provider business mailing address

710 HOSPITAL DR
CRESTVIEW FL
32539-7380
US

V. Phone/Fax

Practice location:
  • Phone: 850-398-8480
  • Fax: 850-398-8482
Mailing address:
  • Phone: 850-398-8480
  • Fax: 850-398-8482

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MICHAEL D GILMORE
Title or Position: PRESIDENT
Credential: MD
Phone: 850-398-8480