=====================================================
General NPI Number Information
=====================================================
NPI Number | 1235150863
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PANAMA CITY PEDIATRICS PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/21/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1937 HARRISON AVE
-----------------------------------------------------
City | PANAMA CITY
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32405-4543
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 850-747-3048
-----------------------------------------------------
Fax | 850-747-0194
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 15697
-----------------------------------------------------
City | PANAMA CITY
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32406-5697
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 850-747-3048
-----------------------------------------------------
Fax | 850-747-0194
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. EEHAB A KENAWY
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 850-747-3661
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208000000X
-----------------------------------------------------
Taxonomy Name | Pediatrics Physician
-----------------------------------------------------
License Number | ME91470
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------