Provider Demographics
NPI:1194810762
Name:OKALOOSA SURGICAL ASSOCIATES, PA
Entity type:Organization
Organization Name:OKALOOSA SURGICAL ASSOCIATES, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:HANEY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:850-678-6601
Mailing Address - Street 1:550 TWIN CITIES BLVD
Mailing Address - Street 2:SUITE C
Mailing Address - City:NICEVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32578
Mailing Address - Country:US
Mailing Address - Phone:850-678-6601
Mailing Address - Fax:850-678-0842
Practice Address - Street 1:550 TWIN CITIES BLVD
Practice Address - Street 2:SUITE C
Practice Address - City:NICEVILLE
Practice Address - State:FL
Practice Address - Zip Code:32578
Practice Address - Country:US
Practice Address - Phone:850-678-6601
Practice Address - Fax:850-678-0842
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-03
Last Update Date:2010-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
208600000X
FLME0055821208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1194810762OtherNPI
FL370716400Medicaid
FLF34413Medicare UPIN