Healthcare Provider Details

I. General information

NPI: 1629918347
Provider Name (Legal Business Name): FORT WALTON BEACH MEDICAL CENTER, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/31/2026
Last Update Date: 03/31/2026
Certification Date: 03/31/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 TEQUESTA DR
DESTIN FL
32541-4758
US

IV. Provider business mailing address

200 TEQUESTA DR
DESTIN FL
32541-4758
US

V. Phone/Fax

Practice location:
  • Phone: 850-837-9194
  • Fax:
Mailing address:
  • Phone: 850-837-9194
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QE0002X
TaxonomyEmergency Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: KENNETH DONAHEY II
Title or Position: CEO
Credential:
Phone: 850-862-1111