Provider Demographics
NPI:1194769950
Name:FT. WALTON BEACH GENERAL SURGERY LLC
Entity type:Organization
Organization Name:FT. WALTON BEACH GENERAL SURGERY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP
Authorized Official - Prefix:
Authorized Official - First Name:MICKEY
Authorized Official - Middle Name:
Authorized Official - Last Name:PICKLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:850-864-3232
Mailing Address - Street 1:1775 LEWIS TURNER BLVD
Mailing Address - Street 2:#102
Mailing Address - City:FT WALTON BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32547-1221
Mailing Address - Country:US
Mailing Address - Phone:850-864-3232
Mailing Address - Fax:
Practice Address - Street 1:1775 LEWIS TURNER BLVD
Practice Address - Street 2:#102
Practice Address - City:FT WALTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:32547-1221
Practice Address - Country:US
Practice Address - Phone:850-864-3232
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-15
Last Update Date:2007-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLDD8316Medicare ID - Type UnspecifiedRR MEDICARE
FLK7184Medicare ID - Type Unspecified