MEDICARE: NORTH LAGOON MEDICAL, LLC

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	363A00000X	Physician Assistant	PA3330	FL

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
2	S74011	OTHER	FL	UPIN
3	Y0A3J	OTHER	FL	BCBS

General Provider Information

NPI Number	:	1770922007
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NORTH LAGOON MEDICAL, LLC

Provider Business Mailing Address
First Line	:	8317 FRONT BEACH RD
Second Line	:
City	:	PANAMA CITY BEACH
State	:	FL
Zip	:	32407-4885
Country	:	US
Telephone Number	:	352-504-8546
Fax Number	:

Provider Business Practice Location Address
First Line	:	8317 FRONT BEACH RD STE 37B
Second Line	:
City	:	PANAMA CITY BEACH
State	:	FL
Zip	:	32407-4896
Country	:	US
Telephone Number	:	352-504-8546
Fax Number	:

Authorized Official
Title or Position	:	MGR
Name	:	RONALD JOSEPH ALDRIDGE
Credential	:	PA
Telephone Number	:	352-504-8546

Provider Enumeration Date	:	06/20/2013
Last Update Date	:	06/20/2013

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