Healthcare Provider Details

I. General information

NPI: 1225214182
Provider Name (Legal Business Name): MEDIGYNE ASSOCIATES CH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/10/2008
Last Update Date: 10/19/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2202 STATE AVE STE 311
PANAMA CITY FL
32405-4590
US

IV. Provider business mailing address

2202 STATE AVE STE 311
PANAMA CITY FL
32405-4590
US

V. Phone/Fax

Practice location:
  • Phone: 850-747-4963
  • Fax: 850-747-0074
Mailing address:
  • Phone: 850-747-4963
  • Fax: 850-747-0074

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207VG0400X
TaxonomyGynecology Physician
License NumberME0012877
License Number StateFL

VIII. Authorized Official

Name: DR. JAMES WILLIAM DERUITER
Title or Position: PRESIDENT
Credential: M.D.
Phone: 850-747-4963