MEDICARE: SURGICAL ASSOCIATES OF NORTHWEST FL 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	208600000X	Surgery Physician	NOT APPLICABLE	FL

General Provider Information

NPI Number	:	1922031343
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SURGICAL ASSOCIATES OF NORTHWEST FL PA

Provider Business Mailing Address
First Line	:	740 HARRISON AVE
Second Line	:
City	:	PANAMA CITY
State	:	FL
Zip	:	32401-2524
Country	:	US
Telephone Number	:	850-785-3232
Fax Number	:	850-747-8648

Provider Business Practice Location Address
First Line	:	740 HARRISON AVE
Second Line	:
City	:	PANAMA CITY
State	:	FL
Zip	:	32401-2524
Country	:	US
Telephone Number	:	850-785-3232
Fax Number	:	850-747-8648

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. RICHARD BOULWARE WILSON
Credential	:	M.D.
Telephone Number	:	850-785-3232

Provider Enumeration Date	:	07/09/2006
Last Update Date	:	08/22/2020

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