Provider Demographics
NPI:1477501153
Name:PENSACOLA NEPHROLOGY PA
Entity Type:Organization
Organization Name:PENSACOLA NEPHROLOGY PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:PATRICIA
Authorized Official - Middle Name:
Authorized Official - Last Name:BREELAND
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:850-444-4700
Mailing Address - Street 1:PO BOX 11037
Mailing Address - Street 2:
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32524-1037
Mailing Address - Country:US
Mailing Address - Phone:850-444-7000
Mailing Address - Fax:850-444-8144
Practice Address - Street 1:4304 LANCASTER DR
Practice Address - Street 2:
Practice Address - City:NICEVILLE
Practice Address - State:FL
Practice Address - Zip Code:32578-4563
Practice Address - Country:US
Practice Address - Phone:850-862-2385
Practice Address - Fax:850-862-0482
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-04
Last Update Date:2021-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL256870500Medicaid
FL256870502Medicaid
FL256870501Medicaid
FL256870507Medicaid
FL256870504Medicaid
FL256870503Medicaid
FL256870505Medicaid
FL256870506Medicaid
FL256870508Medicaid
FL256870507Medicaid