Provider Demographics
NPI:1306822911
Name:PEA RIDGE FAMILY CARE CENTER INC
Entity Type:Organization
Organization Name:PEA RIDGE FAMILY CARE CENTER INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:PURUSHOTTAM
Authorized Official - Middle Name:K
Authorized Official - Last Name:GARG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:850-995-8811
Mailing Address - Street 1:PO BOX 2276
Mailing Address - Street 2:
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32513-2276
Mailing Address - Country:US
Mailing Address - Phone:850-995-8811
Mailing Address - Fax:850-995-8810
Practice Address - Street 1:5553 HIGHWAY 90
Practice Address - Street 2:
Practice Address - City:PACE
Practice Address - State:FL
Practice Address - Zip Code:32571-1540
Practice Address - Country:US
Practice Address - Phone:850-995-8811
Practice Address - Fax:850-995-8810
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-16
Last Update Date:2011-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL251128200Medicaid
FL38616OtherBLUE CROSS BLUE SHIELD
FL251128200Medicaid