Healthcare Provider Details

I. General information

NPI: 1134463482
Provider Name (Legal Business Name): PANHANDLE ORTHOPAEDICS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/26/2012
Last Update Date: 08/23/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12909 PANAMA CITY BEACH PKWY
PANAMA CITY BEACH FL
32407
US

IV. Provider business mailing address

710 HOSPITAL DR
CRESTVIEW FL
32539-7380
US

V. Phone/Fax

Practice location:
  • Phone: 850-784-7724
  • Fax: 850-784-4711
Mailing address:
  • Phone: 850-398-8480
  • Fax: 850-398-8482

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code207XX0005X
TaxonomySports Medicine (Orthopaedic Surgery) Physician
License Number
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code2080S0010X
TaxonomyPediatric Sports Medicine Physician
License Number
License Number StateFL
# 4
Primary TaxonomyN
Taxonomy Code2081S0010X
TaxonomySports Medicine (Physical Medicine & Rehabilitation) Physician
License Number
License Number StateFL
# 5
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number StateFL
# 6
Primary TaxonomyN
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License Number
License Number StateFL
# 7
Primary TaxonomyN
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number
License Number StateFL
# 8
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number StateFL
# 9
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number
License Number StateFL

VIII. Authorized Official

Name: MICHAEL D GILMORE
Title or Position: PRESIDENT/OWNER
Credential: MD
Phone: 850-398-8480