Provider Demographics
NPI:1568420735
Name:4MD2 PHYSICIAN SERVICES OF FORT WALTON BEACH LLC
Entity Type:Organization
Organization Name:4MD2 PHYSICIAN SERVICES OF FORT WALTON BEACH LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:GUY
Authorized Official - Middle Name:DUWANE
Authorized Official - Last Name:HOOPER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:205-437-6098
Mailing Address - Street 1:PO BOX 88452
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60680-1452
Mailing Address - Country:US
Mailing Address - Phone:205-437-6098
Mailing Address - Fax:205-437-5998
Practice Address - Street 1:1000 MAR WALT DR
Practice Address - Street 2:
Practice Address - City:FORT WALTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:32547-6708
Practice Address - Country:US
Practice Address - Phone:850-863-7607
Practice Address - Fax:205-437-5998
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-03
Last Update Date:2007-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLDE2947OtherRRMC GROUP NUMBER
ALF938OtherBCBS GROUP PROVIDER NO
FL2622096OtherUNITEDHEALTHCARE OF FL
FL7800781OtherAETNA GROUP PROVIDER NO
FL97859OtherBCBS GROUP NUMBER
ALF938OtherBCBS GROUP PROVIDER NO