=====================================================
General NPI Number Information
=====================================================
NPI Number | 1326749581
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ERIC DANIEL SHIDE
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/15/2023
-----------------------------------------------------
Last Update Date | 03/05/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 350 CRAG RD
-----------------------------------------------------
City | PANAMA CITY BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32407-7013
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 850-235-5218
-----------------------------------------------------
Fax | 850-235-5993
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 350 CRAG RD
-----------------------------------------------------
City | PANAMA CITY BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32407-7013
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 850-235-5218
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208D00000X
-----------------------------------------------------
Taxonomy Name | General Practice Physician
-----------------------------------------------------
License Number | 0101283506
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------