MEDICARE: PEA RIDGE FAMILY CARE CENTER INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1013587955
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PEA RIDGE FAMILY CARE CENTER INC

Provider Business Mailing Address
First Line	:	5553 HIGHWAY 90
Second Line	:
City	:	PACE
State	:	FL
Zip	:	32571-1540
Country	:	US
Telephone Number	:	850-995-8811
Fax Number	:	850-995-8810

Provider Business Practice Location Address
First Line	:	5500 N DAVIS HWY STE 2
Second Line	:
City	:	PENSACOLA
State	:	FL
Zip	:	32503-2063
Country	:	US
Telephone Number	:	850-475-0867
Fax Number	:	850-475-0895

Authorized Official
Title or Position	:	OWNER
Name	:	PURUSHOTTAM K. GARG
Credential	:	MD
Telephone Number	:	850-995-8811

Provider Enumeration Date	:	07/01/2021
Last Update Date	:	07/01/2021

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