Provider Demographics
NPI:1699970962
Name:OKALOOSA MENTAL HEALTH & PSYCHIATRIC CENTER, INC.
Entity type:Organization
Organization Name:OKALOOSA MENTAL HEALTH & PSYCHIATRIC CENTER, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:KIUMARS
Authorized Official - Middle Name:
Authorized Official - Last Name:SHAMS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:850-432-3334
Mailing Address - Street 1:101 S JEFFERSON ST
Mailing Address - Street 2:SUITE C
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32502-5656
Mailing Address - Country:US
Mailing Address - Phone:850-432-3334
Mailing Address - Fax:850-432-3353
Practice Address - Street 1:101 S JEFFERSON ST
Practice Address - Street 2:SUITE C
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32502-5656
Practice Address - Country:US
Practice Address - Phone:850-432-3334
Practice Address - Fax:850-432-3353
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-18
Last Update Date:2012-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME299492084A0401X, 2084N0400X, 2084N0402X, 2084P0005X, 2084P0800X, 2084P0802X, 2084P0804X, 2084P0805X, 2084P2900X, 208U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty
No2084A0401XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyAddiction MedicineGroup - Multi-Specialty
No2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Multi-Specialty
No2084N0402XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology with Special Qualifications in Child NeurologyGroup - Multi-Specialty
No2084P0005XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurodevelopmental DisabilitiesGroup - Multi-Specialty
No2084P0802XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyAddiction PsychiatryGroup - Multi-Specialty
No2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent PsychiatryGroup - Multi-Specialty
No2084P0805XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyGeriatric PsychiatryGroup - Multi-Specialty
No2084P2900XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPain MedicineGroup - Multi-Specialty
No208U00000XAllopathic & Osteopathic PhysiciansClinical PharmacologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL79178OtherBC BS FL
FL038295700Medicaid
FL79178OtherBC BS FL
FL038295700Medicaid
FLK6022Medicare ID - Type UnspecifiedMEDICARE NUMBER