Provider Demographics
NPI:1255320636
Name:PENSACOLA PRIMARY CARE INC
Entity Type:Organization
Organization Name:PENSACOLA PRIMARY CARE INC
Other - Org Name:DBA PENSACOLA PRIMARY CARE, INC.-NINE MILE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:MICKEY
Authorized Official - Middle Name:
Authorized Official - Last Name:PICKLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:850-523-2117
Mailing Address - Street 1:1190 E NINE MILE RD
Mailing Address - Street 2:
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32514-1651
Mailing Address - Country:US
Mailing Address - Phone:850-474-8771
Mailing Address - Fax:850-479-9180
Practice Address - Street 1:1190 E NINE MILE RD
Practice Address - Street 2:
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32514-1651
Practice Address - Country:US
Practice Address - Phone:850-474-8771
Practice Address - Fax:850-479-9180
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-18
Last Update Date:2007-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLK2580Medicare ID - Type Unspecified