Provider Demographics
NPI:1538504063
Name:EGLIN AIR FORCE BASE RESIDENCY PROGRAM
Entity Type:Organization
Organization Name:EGLIN AIR FORCE BASE RESIDENCY PROGRAM
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROGRAM DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:
Authorized Official - Last Name:PAULSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:850-883-8192
Mailing Address - Street 1:11850 DR MARTIN LUTHER KING JR ST N
Mailing Address - Street 2:APT 22-312
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33716-1619
Mailing Address - Country:US
Mailing Address - Phone:206-883-5357
Mailing Address - Fax:
Practice Address - Street 1:11850 DR MARTIN LUTHER KING JR ST N
Practice Address - Street 2:APT 22-312
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33716-1619
Practice Address - Country:US
Practice Address - Phone:206-883-5357
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-05-10
Last Update Date:2013-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL207Q00000X, 261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No261Q00000XAmbulatory Health Care FacilitiesClinic/CenterGroup - Single Specialty