Provider Demographics
NPI:1568409837
Name:BEACH PRIMARY CARE LLC
Entity Type:Organization
Organization Name:BEACH PRIMARY CARE LLC
Other - Org Name:WEST END OF THE BEACH PRIMARY CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VP
Authorized Official - Prefix:
Authorized Official - First Name:MICKEY
Authorized Official - Middle Name:
Authorized Official - Last Name:PICKLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:850-234-8175
Mailing Address - Street 1:17320 PANAMA CITY BEACH PKWY
Mailing Address - Street 2:SUITE 105
Mailing Address - City:PANAMA CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32413-2024
Mailing Address - Country:US
Mailing Address - Phone:850-234-8175
Mailing Address - Fax:850-234-8868
Practice Address - Street 1:17320 PANAMA CITY BEACH PKWY
Practice Address - Street 2:SUITE 105
Practice Address - City:PANAMA CITY
Practice Address - State:FL
Practice Address - Zip Code:32413-2024
Practice Address - Country:US
Practice Address - Phone:850-234-8175
Practice Address - Fax:850-234-8868
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-02
Last Update Date:2008-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLDE9061Medicare PIN
FLK9673Medicare PIN