Healthcare Provider Details

I. General information

NPI: 1003314915
Provider Name (Legal Business Name): THE ANTI-AGING CLINIC OF NORTHWEST FLORIDA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/25/2018
Last Update Date: 01/25/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3019 OSPREY CIR
PANAMA CITY FL
32405
US

IV. Provider business mailing address

3019 OSPREY CIR
PANAMA CITY FL
32405
US

V. Phone/Fax

Practice location:
  • Phone: 850-630-8368
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207VB0002X
TaxonomyObesity Medicine (Obstetrics & Gynecology) Physician
License NumberME107784
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code207VG0400X
TaxonomyGynecology Physician
License NumberME107784
License Number StateFL

VIII. Authorized Official

Name: MR. TIMOTHY JOHN RAMSDEN
Title or Position: OWNER/PRESIDENT
Credential: MD
Phone: 850-630-8368