Provider Demographics
NPI:1255319695
Name:SAMUEL E WARD MD PL
Entity Type:Organization
Organization Name:SAMUEL E WARD MD PL
Other - Org Name:WARD MEDICAL CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JESSICA
Authorized Official - Middle Name:JEAN
Authorized Official - Last Name:HAWKINS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:850-547-3679
Mailing Address - Street 1:3803 GALILEE RD
Mailing Address - Street 2:
Mailing Address - City:GRACEVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32440-4721
Mailing Address - Country:US
Mailing Address - Phone:850-547-3679
Mailing Address - Fax:855-492-6785
Practice Address - Street 1:3607 ROCHE AVE
Practice Address - Street 2:
Practice Address - City:VERNON
Practice Address - State:FL
Practice Address - Zip Code:32462-3358
Practice Address - Country:US
Practice Address - Phone:850-547-3679
Practice Address - Fax:855-492-6785
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-05
Last Update Date:2023-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
35511OtherBLUE SHIELD
FL266048200Medicaid
K7417Medicare ID - Type Unspecified