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NPI Code Detail

MEDICARE: PREMIER MEDICAL PEDIATRICS CLINIC INC

MEDICARE: PREMIER MEDICAL PEDIATRICS CLINIC 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
1261QR1300XRural Health Clinic/Center
2208000000XPediatrics Physician

General Provider Information

NPI Number : 1831342880
Entity Type Code : Organization
Provider Name (Legal Business Name) : PREMIER MEDICAL PEDIATRICS CLINIC INC
Provider Business Mailing Address
First Line : PO BOX 719
Second Line :
City : PERRY
State : FL
Zip : 32348-0719
Country : US
Telephone Number : 850-584-3278
Fax Number : 850-584-8171
Provider Business Practice Location Address
First Line : 315 E ASH ST
Second Line :
City : PERRY
State : FL
Zip : 32347-2029
Country : US
Telephone Number : 850-838-2121
Fax Number : 850-838-1842
Authorized Official
Title or Position : CFO
Name : MS. LAURIE SANTANA
Credential :
Telephone Number : 850-584-3278
Provider Enumeration Date : 11/03/2008
Last Update Date : 02/08/2010

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1861440141 — TAE YU DO
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1205885613 — ABDUL HAMID SOFI M.D.
Practice Location Address:
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1942472162 — JACKIE LYNN WALSINGHAM LMT
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Directions to “PREMIER MEDICAL PEDIATRICS CLINIC INC ” Practice Location

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