Provider Demographics
NPI:1407113897
Name:INFECTIOUS DISEASES EXPERT GROUP OF NW FLORIDA LLC
Entity Type:Organization
Organization Name:INFECTIOUS DISEASES EXPERT GROUP OF NW FLORIDA LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:ISSA
Authorized Official - Middle Name:E
Authorized Official - Last Name:EPHTIMIOS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:850-912-8433
Mailing Address - Street 1:9013 UNIVERSITY PKWY
Mailing Address - Street 2:SUITE H
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32514-9416
Mailing Address - Country:US
Mailing Address - Phone:850-912-8433
Mailing Address - Fax:850-912-8584
Practice Address - Street 1:9013 UNIVERSITY PKWY
Practice Address - Street 2:SUITE H
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32514-9416
Practice Address - Country:US
Practice Address - Phone:850-912-8433
Practice Address - Fax:850-912-8584
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DR. ISSA EPHTIMIOS
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-04-23
Last Update Date:2012-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME101155174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty