Provider Demographics
NPI:1992740229
Name:BLUEWATER BAY UROLOGY LLC
Entity type:Organization
Organization Name:BLUEWATER BAY UROLOGY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
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:850-523-2117
Mailing Address - Street 1:4566 E HIGHWAY 20
Mailing Address - Street 2:SUITE 102
Mailing Address - City:NICEVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32578-8838
Mailing Address - Country:US
Mailing Address - Phone:850-897-6005
Mailing Address - Fax:850-897-6003
Practice Address - Street 1:4566 E HIGHWAY 20
Practice Address - Street 2:SUITE 102
Practice Address - City:NICEVILLE
Practice Address - State:FL
Practice Address - Zip Code:32578-8838
Practice Address - Country:US
Practice Address - Phone:850-897-6005
Practice Address - Fax:850-897-6003
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-19
Last Update Date:2008-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLAC202Medicare PIN
FLDF6999Medicare PIN