MEDICARE: PENSACOLA NEPHROLOGY PA

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	207RN0300X	Nephrology Physician

General Provider Information

NPI Number	:	1053252684
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PENSACOLA NEPHROLOGY PA

Provider Business Mailing Address
First Line	:	67 JOE CAMPBELL RD
Second Line	:
City	:	FREEPORT
State	:	FL
Zip	:	32439-4418
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	67 JOE CAMPBELL RD
Second Line	:
City	:	FREEPORT
State	:	FL
Zip	:	32439-4418
Country	:	US
Telephone Number	:	850-862-2385
Fax Number	:

Authorized Official
Title or Position	:	CREDENTIALING SPECIALIST
Name	:	AMANDA ROBERSON
Credential	:
Telephone Number	:	850-444-4700

Provider Enumeration Date	:	04/06/2026
Last Update Date	:	04/06/2026

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