Provider Demographics
NPI:1548204357
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:850-434-8144
Practice Address - Street 1:6001 INDUSTRIAL BLVD
Practice Address - Street 2:
Practice Address - City:CENTURY
Practice Address - State:FL
Practice Address - Zip Code:32535-3312
Practice Address - Country:US
Practice Address - Phone:850-444-4700
Practice Address - Fax:850-444-9766
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-15
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
FL256870503Medicaid
FL256870506Medicaid
FL256870502Medicaid
FL256870501Medicaid
FL256870507Medicaid
FL0358OtherMED3000/HEALTH 1ST NETWOR
FL256870500Medicaid
AL529904030Medicaid
FL99659OtherBCBS OF FLORIDA
FL256870508Medicaid
FL256870504Medicaid
FL256870505Medicaid
CF9776OtherRR MEDICARE
FL256870504Medicaid
FL256870500Medicaid