Healthcare Provider Details

I. General information

NPI: 1558335869
Provider Name (Legal Business Name): KETCHUM WOOD & BURGERT CHARTERED DRS KETCHUM WOOD & BURGERT
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/14/2006
Last Update Date: 05/15/2020
Certification Date: 05/15/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1899 EIDER CT
TALLAHASSEE FL
32308-4537
US

IV. Provider business mailing address

1899 EIDER CT
TALLAHASSEE FL
32308-4537
US

V. Phone/Fax

Practice location:
  • Phone: 850-878-5143
  • Fax: 850-942-6622
Mailing address:
  • Phone: 850-878-5143
  • Fax: 850-942-6622

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number800000042
License Number StateFL

VIII. Authorized Official

Name: ANGELA FUQUA
Title or Position: ADMINISTRATOR
Credential:
Phone: 850-219-7603