Provider Demographics
NPI:1164443172
Name:FORT WALTON BEACH HEART & LUNG SURGERY
Entity Type:Organization
Organization Name:FORT WALTON BEACH HEART & LUNG SURGERY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:KIM
Authorized Official - Middle Name:
Authorized Official - Last Name:RILEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:850-651-9300
Mailing Address - Street 1:PO BOX 1150
Mailing Address - Street 2:
Mailing Address - City:SHALIMAR
Mailing Address - State:FL
Mailing Address - Zip Code:32579-5150
Mailing Address - Country:US
Mailing Address - Phone:850-651-9300
Mailing Address - Fax:850-651-3345
Practice Address - Street 1:1283 EGLIN PKWY
Practice Address - Street 2:SUITE B
Practice Address - City:SHALIMAR
Practice Address - State:FL
Practice Address - Zip Code:32579-1256
Practice Address - Country:US
Practice Address - Phone:850-651-9300
Practice Address - Fax:850-651-3345
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-22
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME 87486208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)Group - Multi-Specialty