Provider Demographics
NPI:1558531905
Name:AVALON MEDICAL GROUP
Entity Type:Organization
Organization Name:AVALON MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZED AGENT
Authorized Official - Prefix:MS
Authorized Official - First Name:KATHERINE
Authorized Official - Middle Name:K
Authorized Official - Last Name:STANLEY
Authorized Official - Suffix:
Authorized Official - Credentials:ARNP-BC
Authorized Official - Phone:850-485-7341
Mailing Address - Street 1:PO BOX 10209
Mailing Address - Street 2:
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32524-0209
Mailing Address - Country:US
Mailing Address - Phone:850-476-4200
Mailing Address - Fax:866-684-0566
Practice Address - Street 1:1900 SUMMIT BLVD
Practice Address - Street 2:
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32503-3359
Practice Address - Country:US
Practice Address - Phone:850-436-5900
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-01
Last Update Date:2012-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL00A0POtherBLUE CROSS BLUE SHIELD OF FLORIDA
FL001078000Medicaid