Healthcare Provider Details

I. General information

NPI: 1518973908
Provider Name (Legal Business Name): 96TH MDG EGLIN AFB
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/31/2006
Last Update Date: 06/13/2008
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

895 SANTA ROSA BLVD APT 312
FORT WALTON BEACH FL
32548-1907
US

V. Phone/Fax

Practice location:
  • Phone: 850-862-1111
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code286500000X
TaxonomyMilitary Hospital
License Number02002895A
License Number StateIN

VIII. Authorized Official

Name: DR. ERIC HOLT
Title or Position: STAFF ANESTHESIOLOGIST
Credential:
Phone: 617-840-8249