Healthcare Provider Details

I. General information

NPI: 1194810762
Provider Name (Legal Business Name): OKALOOSA SURGICAL ASSOCIATES, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/03/2006
Last Update Date: 09/16/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

550 TWIN CITIES BLVD SUITE C
NICEVILLE FL
32578
US

IV. Provider business mailing address

550 TWIN CITIES BLVD SUITE C
NICEVILLE FL
32578
US

V. Phone/Fax

Practice location:
  • Phone: 850-678-6601
  • Fax: 850-678-0842
Mailing address:
  • Phone: 850-678-6601
  • Fax: 850-678-0842

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberME0055821
License Number StateFL

VIII. Authorized Official

Name: WILLIAM MICHAEL HANEY
Title or Position: PHYSICIAN
Credential: MD
Phone: 850-678-6601