Healthcare Provider Details

I. General information

NPI: 1144022146
Provider Name (Legal Business Name): BEACHSIDE MEDICAL GROUP LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/27/2025
Last Update Date: 08/15/2025
Certification Date: 08/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

123 BAPTIST WAY
PENSACOLA FL
32503-2254
US

IV. Provider business mailing address

4951 GRANDE DR
PENSACOLA FL
32504-8965
US

V. Phone/Fax

Practice location:
  • Phone: 850-473-0100
  • Fax: 850-473-0500
Mailing address:
  • Phone: 850-473-0100
  • Fax: 850-473-0500

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080N0001X
TaxonomyNeonatal-Perinatal Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: JACLYN H. HAVINGA
Title or Position: PRESIDENT
Credential: MD
Phone: 850-473-0100