Provider Demographics
NPI:1568436962
Name:325 MDG
Entity Type:Organization
Organization Name:325 MDG
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:325 MDG COMMANDER
Authorized Official - Prefix:DR
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:
Authorized Official - Last Name:NICHOLAS
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:850-283-7515
Mailing Address - Street 1:2405 MAPLE CT
Mailing Address - Street 2:
Mailing Address - City:PANAMA CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32404-3047
Mailing Address - Country:US
Mailing Address - Phone:850-283-7511
Mailing Address - Fax:850-283-7721
Practice Address - Street 1:325 MDG BLDG
Practice Address - Street 2:1305 SUWANNEE AVE
Practice Address - City:TYNDALL AFB
Practice Address - State:FL
Practice Address - Zip Code:32403
Practice Address - Country:US
Practice Address - Phone:850-283-7511
Practice Address - Fax:850-283-7721
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-14
Last Update Date:2008-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY5848103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty