Provider Demographics
NPI:1174657332
Name:INFECTIOUS DISEASES ASSOCIATES OF NORTHWEST FLORIDA PA
Entity Type:Organization
Organization Name:INFECTIOUS DISEASES ASSOCIATES OF NORTHWEST FLORIDA PA
Other - Org Name:CENTER FOR PREVENTION AND TREATMENT OF INFECTIONS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BARBARA
Authorized Official - Middle Name:H
Authorized Official - Last Name:WADE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:850-476-3131
Mailing Address - Street 1:5153 N 9TH AVE
Mailing Address - Street 2:SUITE 305
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32504-5719
Mailing Address - Country:US
Mailing Address - Phone:850-476-3131
Mailing Address - Fax:850-476-4848
Practice Address - Street 1:5153 N 9TH AVE
Practice Address - Street 2:SUITE 305
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32504-5719
Practice Address - Country:US
Practice Address - Phone:850-476-3131
Practice Address - Fax:850-476-4848
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-16
Last Update Date:2012-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL601606207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL251839200Medicaid
FLK1568Medicare ID - Type Unspecified