Provider Demographics
NPI:1043396245
Name:WEST FLORIDA MEDICAL CENTER CLINIC PA
Entity Type:Organization
Organization Name:WEST FLORIDA MEDICAL CENTER CLINIC PA
Other - Org Name:MEDICAL CENTER CLINIC AMBULATORY SURGICAL CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MARSHALL
Authorized Official - Middle Name:ANDY
Authorized Official - Last Name:POPPLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:850-474-8724
Mailing Address - Street 1:8333 N DAVIS HWY
Mailing Address - Street 2:
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32514-6050
Mailing Address - Country:US
Mailing Address - Phone:850-969-2121
Mailing Address - Fax:850-969-2989
Practice Address - Street 1:8333 N DAVIS HWY
Practice Address - Street 2:
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32514-6050
Practice Address - Country:US
Practice Address - Phone:850-969-2121
Practice Address - Fax:850-969-2989
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WEST FLORIDA MEDICAL CENTER CLINIC PA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-10-31
Last Update Date:2012-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL791261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
68-01811OtherUNITED HEALTH CARE
GA490002804OtherPALMETO MEDICARE
FL079184900Medicaid
64COtherBLUE CROSS OF FLORIDA
FL079184900Medicaid