=====================================================
General NPI Number Information
=====================================================
NPI Number | 1801940549
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PRIMECARE OF NW FL
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/22/2007
-----------------------------------------------------
Last Update Date | 09/10/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 625 W BALDWIN RD STE C
-----------------------------------------------------
City | PANAMA CITY
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32405
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 850-769-6612
-----------------------------------------------------
Fax | 850-769-3533
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 1568
-----------------------------------------------------
City | LYNN HAVEN
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32404-1568
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATOR
-----------------------------------------------------
Name | MRS. KIMBERLY DALE SHINSKY
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 850-769-6612
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 5075
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------