Healthcare Provider Details

I. General information

NPI: 1871683854
Provider Name (Legal Business Name): MARIANNA PEDIATRIC ASSOCIATES PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/13/2006
Last Update Date: 06/20/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4230 HOSPITAL DR STE 102
MARIANNA FL
32446-1934
US

IV. Provider business mailing address

4230 HOSPITAL DR STE 102
MARIANNA FL
32446-1934
US

V. Phone/Fax

Practice location:
  • Phone: 850-482-2004
  • Fax: 850-482-4778
Mailing address:
  • Phone: 850-482-2004
  • Fax: 850-482-4778

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberME57543
License Number StateFL

VIII. Authorized Official

Name: DOYLE LON BOSSE
Title or Position: DOCTOR OWNER
Credential: MD
Phone: 850-482-2004