Healthcare Provider Details

I. General information

NPI: 1043652498
Provider Name (Legal Business Name): MAR-WALT DRIVE EMERGENCY PHYSICIANS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/26/2013
Last Update Date: 07/26/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 MAR WALT DR
FORT WALTON BEACH FL
32547-6708
US

IV. Provider business mailing address

815 S PALAFOX ST STE 300
PENSACOLA FL
32502-5960
US

V. Phone/Fax

Practice location:
  • Phone: 850-863-7610
  • Fax: 800-305-3233
Mailing address:
  • Phone: 800-444-7009
  • Fax: 800-305-3233

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207PP0204X
TaxonomyPediatric Emergency Medicine (Emergency Medicine) Physician
License Number
License Number State

VIII. Authorized Official

Name: JOSEPH H. GATEWOOD
Title or Position: PRESIDENT
Credential: MD
Phone: 800-444-7009