Provider Demographics
NPI:1518975143
Name:OBSTETRICS & GYNECOLOGY PA
Entity Type:Organization
Organization Name:OBSTETRICS & GYNECOLOGY PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:KATHRYN
Authorized Official - Middle Name:A
Authorized Official - Last Name:STEVENS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:850-863-1000
Mailing Address - Street 1:1703 LEWIS TURNER BLVD
Mailing Address - Street 2:
Mailing Address - City:FORT WALTON BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32547-1221
Mailing Address - Country:US
Mailing Address - Phone:850-863-1000
Mailing Address - Fax:850-863-0800
Practice Address - Street 1:1703 LEWIS TURNER BLVD
Practice Address - Street 2:
Practice Address - City:FORT WALTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:32547-1221
Practice Address - Country:US
Practice Address - Phone:850-863-1000
Practice Address - Fax:850-863-0800
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-03
Last Update Date:2010-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME84285207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL264593900Medicaid
FL11131OtherBCBS OF FL
FL264593900Medicaid
FLK3609Medicare ID - Type UnspecifiedMEDICARE GROUP
FL11131ZMedicare ID - Type UnspecifiedMEDICARE INDIVIDUAL