Provider Demographics
NPI:1467437277
Name:WHITE-WILSON MEDICAL CENTER PA
Entity Type:Organization
Organization Name:WHITE-WILSON MEDICAL CENTER PA
Other - Org Name:WHITE-WILSON MEDICAL CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEDICAL STAFF COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:KATHY
Authorized Official - Middle Name:A
Authorized Official - Last Name:LEEPER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:850-863-8150
Mailing Address - Street 1:1005 MAR WALT DR
Mailing Address - Street 2:ADMINISTRATION
Mailing Address - City:FORT WALTON BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32547-6707
Mailing Address - Country:US
Mailing Address - Phone:850-863-8131
Mailing Address - Fax:850-863-4152
Practice Address - Street 1:1005 MAR WALT DR
Practice Address - Street 2:ADMINISTRATION
Practice Address - City:FORT WALTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:32547-6707
Practice Address - Country:US
Practice Address - Phone:850-863-8131
Practice Address - Fax:850-863-4152
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-14
Last Update Date:2019-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL059722800Medicaid
FL0762190001Medicare NSC
FL99017Medicare PIN