Healthcare Provider Details

I. General information

NPI: 1164443172
Provider Name (Legal Business Name): FORT WALTON BEACH HEART & LUNG SURGERY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/22/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1283 EGLIN PKWY SUITE B
SHALIMAR FL
32579-1256
US

IV. Provider business mailing address

PO BOX 1150
SHALIMAR FL
32579-5150
US

V. Phone/Fax

Practice location:
  • Phone: 850-651-9300
  • Fax: 850-651-3345
Mailing address:
  • Phone: 850-651-9300
  • Fax: 850-651-3345

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208G00000X
TaxonomyThoracic Surgery (Cardiothoracic Vascular Surgery) Physician
License NumberME 87486
License Number StateFL

VIII. Authorized Official

Name: KIM RILEY
Title or Position: BILLING COORDINATOR
Credential:
Phone: 850-651-9300