Provider Demographics
NPI:1518973908
Name:96TH MDG EGLIN AFB
Entity Type:Organization
Organization Name:96TH MDG EGLIN AFB
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:STAFF ANESTHESIOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:ERIC
Authorized Official - Middle Name:
Authorized Official - Last Name:HOLT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:617-840-8249
Mailing Address - Street 1:895 SANTA ROSA BLVD APT 312
Mailing Address - Street 2:
Mailing Address - City:FORT WALTON BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32548-1907
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1000 MAR WALT DR
Practice Address - Street 2:
Practice Address - City:FORT WALTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:32547-6708
Practice Address - Country:US
Practice Address - Phone:850-862-1111
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-31
Last Update Date:2008-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN02002895A286500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes286500000XHospitalsMilitary Hospital