Provider Demographics
NPI:1336281773
Name:MARK J TENHOLDER MD PA
Entity Type:Organization
Organization Name:MARK J TENHOLDER MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:J
Authorized Official - Last Name:TENHOLDER
Authorized Official - Suffix:
Authorized Official - Credentials:MD PA
Authorized Official - Phone:850-863-2153
Mailing Address - Street 1:1034 MAR WALT DR STE 100
Mailing Address - Street 2:
Mailing Address - City:FORT WALTON BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32547-6645
Mailing Address - Country:US
Mailing Address - Phone:850-863-2153
Mailing Address - Fax:850-863-2885
Practice Address - Street 1:1034 MAR WALT DR STE 100
Practice Address - Street 2:
Practice Address - City:FORT WALTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:32547-6645
Practice Address - Country:US
Practice Address - Phone:850-863-2153
Practice Address - Fax:850-863-2885
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-13
Last Update Date:2008-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME89699207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL37804OtherBS PROVIDER ID
5232980003Medicare NSC
FL5232980002Medicare NSC
FLK6469Medicare PIN
FL37804ZMedicare ID - Type UnspecifiedPPIN
FLI18092Medicare UPIN
FL5232980001Medicare NSC