Healthcare Provider Details

I. General information

NPI: 1962478230
Provider Name (Legal Business Name): FLORIDA PANHANDLE PEDIATRIC FOUNDATION, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/27/2006
Last Update Date: 03/12/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2814 W 15TH ST
PANAMA CITY FL
32401-1376
US

IV. Provider business mailing address

2814 W 15TH ST
PANAMA CITY FL
32401-1376
US

V. Phone/Fax

Practice location:
  • Phone: 850-872-4840
  • Fax: 850-872-4468
Mailing address:
  • Phone: 850-872-4840
  • Fax: 850-872-4468

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MS. PATTI A. WELCH
Title or Position: PROJECT ADMINISTRATOR
Credential: R.N.-BSN
Phone: 850-872-4840