=====================================================
General NPI Number Information
=====================================================
NPI Number | 1013262336
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ST ANDREWS BAY EMERGENCY PHYSICIANS, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/24/2012
-----------------------------------------------------
Last Update Date | 10/30/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 615 N BONITA AVE
-----------------------------------------------------
City | PANAMA CITY
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32401-3623
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 850-760-1511
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 31297
-----------------------------------------------------
City | CLARKSVILLE
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37040-0022
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT/CEO
-----------------------------------------------------
Name | MARK E GREEN
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 931-614-6635
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207P00000X
-----------------------------------------------------
Taxonomy Name | Emergency Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------