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General NPI Number Information
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NPI Number | 1558335869
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Entity Type | Organization
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Legal Business Name | KETCHUM WOOD & BURGERT CHARTERED DRS KETCHUM WOOD & BURGERT
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Dates
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Enumeration Date | 02/14/2006
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Last Update Date | 05/15/2020
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Provider Practice Location Address
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Address Line | 1899 EIDER CT
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City | TALLAHASSEE
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State | FL
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Zip | 32308-4537
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Country | US
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Telephone | 850-878-5143
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Fax | 850-942-6622
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Provider Business Mailing Address
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Address Line | 1899 EIDER CT
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City | TALLAHASSEE
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State | FL
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Zip | 32308-4537
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Country | US
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Telephone | 850-878-5143
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Fax | 850-942-6622
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Authorized Official
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Title or Position | ADMINISTRATOR
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Name | ANGELA FUQUA
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Credential |
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Telephone | 850-219-7603
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 291U00000X
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Taxonomy Name | Clinical Medical Laboratory
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License Number | 800000042
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License Number State | FL
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