Provider Demographics
NPI:1093356685
Name:PRIMARY CARE SOUTH, INC
Entity Type:Organization
Organization Name:PRIMARY CARE SOUTH, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIAL
Authorized Official - Prefix:
Authorized Official - First Name:KIMMIE
Authorized Official - Middle Name:
Authorized Official - Last Name:HUNTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:850-420-5420
Mailing Address - Street 1:5551 US HIGHWAY 98
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32459
Mailing Address - Country:US
Mailing Address - Phone:850-420-5420
Mailing Address - Fax:850-244-8011
Practice Address - Street 1:5551 US HIGHWAY 98
Practice Address - Street 2:
Practice Address - City:SANTA ROSA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32459
Practice Address - Country:US
Practice Address - Phone:850-420-5420
Practice Address - Fax:850-244-8011
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-10-04
Last Update Date:2022-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL104684300Medicaid