=====================================================
General NPI Number Information
=====================================================
NPI Number | 1932477023
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SAMIR M. EBEID
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/05/2011
-----------------------------------------------------
Last Update Date | 12/05/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2202 STATE AVE STE 302
-----------------------------------------------------
City | PANAMA CITY
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32405
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 850-785-0321
-----------------------------------------------------
Fax | 850-784-9955
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2202 STATE AVE STE 302
-----------------------------------------------------
City | PANAMA CITY
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32405
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 850-785-0321
-----------------------------------------------------
Fax | 850-784-9955
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MR. SAMIR MASAN EBEID
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 850-785-0321
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2080P0202X
-----------------------------------------------------
Taxonomy Name | Pediatric Cardiology Physician
-----------------------------------------------------
License Number | ME0046120
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 208000000X
-----------------------------------------------------
Taxonomy Name | Pediatrics Physician
-----------------------------------------------------
License Number | ME0046120
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------