Healthcare Provider Details

I. General information

NPI: 1225432727
Provider Name (Legal Business Name): INVALID NPI
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/14/2014
Last Update Date: 04/02/2024
Certification Date: 04/02/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

801 E 6TH ST SUITE 504
PANAMA CITY FL
32401-3661
US

IV. Provider business mailing address

801 E 6TH ST SUITE 504
PANAMA CITY FL
32401-3661
US

V. Phone/Fax

Practice location:
  • Phone: 850-769-0329
  • Fax:
Mailing address:
  • Phone: 850-769-0329
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number
License Number State

VIII. Authorized Official

Name: GLENDA M COOK
Title or Position: DIRECTOR OF BUSINESS OPERATIONS
Credential:
Phone: 850-769-0329