Healthcare Provider Details

I. General information

NPI: 1629522008
Provider Name (Legal Business Name): MGHMI
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/15/2016
Last Update Date: 09/21/2022
Certification Date: 09/21/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6109 N DAVIS HWY
PENSACOLA FL
32504-6949
US

IV. Provider business mailing address

4311 BAYOU BLVD APT A8
PENSACOLA FL
32503-2621
US

V. Phone/Fax

Practice location:
  • Phone: 850-741-2251
  • Fax: 866-258-9993
Mailing address:
  • Phone: 506-299-3668
  • Fax: 866-258-9993

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number
License Number State

VIII. Authorized Official

Name: MS. MARCIA G MOLLE
Title or Position: OWNER
Credential:
Phone: 727-638-9817