Provider Demographics
NPI:1992701049
Name:NORTHWEST FLORIDA SURGERY CENTER
Entity type:Organization
Organization Name:NORTHWEST FLORIDA SURGERY CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:RON
Authorized Official - Middle Name:NMI
Authorized Official - Last Name:SAMUELIAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:850-747-0400
Mailing Address - Street 1:767 AIRPORT RD
Mailing Address - Street 2:
Mailing Address - City:PANAMA CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32405-4000
Mailing Address - Country:US
Mailing Address - Phone:850-747-0400
Mailing Address - Fax:850-913-9744
Practice Address - Street 1:767 AIRPORT RD
Practice Address - Street 2:
Practice Address - City:PANAMA CITY
Practice Address - State:FL
Practice Address - Zip Code:32405-4000
Practice Address - Country:US
Practice Address - Phone:850-747-0400
Practice Address - Fax:850-913-9744
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-23
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL0000745261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL62NOtherBCBS
FL=========OtherTRICARE
FLF1223Medicare PIN