Provider Demographics
NPI:1558335869
Name:KETCHUM WOOD & BURGERT CHARTERED DRS KETCHUM WOOD & BURGERT
Entity Type:Organization
Organization Name:KETCHUM WOOD & BURGERT CHARTERED DRS KETCHUM WOOD & BURGERT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:ANGELA
Authorized Official - Middle Name:
Authorized Official - Last Name:FUQUA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:850-219-7603
Mailing Address - Street 1:1899 EIDER CT
Mailing Address - Street 2:
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32308-4537
Mailing Address - Country:US
Mailing Address - Phone:850-878-5143
Mailing Address - Fax:850-942-6622
Practice Address - Street 1:1899 EIDER CT
Practice Address - Street 2:
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32308-4537
Practice Address - Country:US
Practice Address - Phone:850-878-5143
Practice Address - Fax:850-942-6622
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-14
Last Update Date:2020-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL800000042291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLL8014OtherBC/BS LAB SERVICES
FLCF6643OtherRAILROAD MEDICARE
FL030063201Medicaid
FLCF6643OtherRAILROAD MEDICARE