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NPI Code Detail

MEDICARE: 4MD2 PHYSICIAN SERVICES OF NICEVILLE LLC

MEDICARE: 4MD2 PHYSICIAN SERVICES OF NICEVILLE 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
1207P00000XEmergency Medicine Physician

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
12621276OTHERFLUNITEDHEALTHCARE OF FL
297861OTHERFLGROUP BCBS NUMBER
37946836OTHERFLAETNA GROUP NO
4DE3244OTHERFLGROUP RRMC NUMBER
5F952OTHERALBCBS GROUP NO

General Provider Information

NPI Number : 1902857972
Entity Type Code : Organization
Provider Name (Legal Business Name) : 4MD2 PHYSICIAN SERVICES OF NICEVILLE LLC
Provider Business Mailing Address
First Line : PO BOX 88490
Second Line :
City : CHICAGO
State : IL
Zip : 60680-1490
Country : US
Telephone Number : 205-437-6098
Fax Number : 205-437-5998
Provider Business Practice Location Address
First Line : 2190 HIGHWAY 85 N
Second Line :
City : NICEVILLE
State : FL
Zip : 32578-1045
Country : US
Telephone Number : 850-729-9490
Fax Number : 205-437-5998
Authorized Official
Title or Position : PRESIDENT
Name : GUY DUWANE HOOPER
Credential :
Telephone Number : 205-437-6098
Provider Enumeration Date : 05/15/2006
Last Update Date : 07/20/2007

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Directions to “4MD2 PHYSICIAN SERVICES OF NICEVILLE LLC ” Practice Location

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