Provider Demographics
NPI:1568452688
Name:WEST FLORIDA MEDICAL CENTER CLINIC, PA
Entity Type:Organization
Organization Name:WEST FLORIDA MEDICAL CENTER CLINIC, PA
Other - Org Name:MEDICAL CENTER CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE VP
Authorized Official - Prefix:
Authorized Official - First Name:MARSHALL
Authorized Official - Middle Name:ANDY
Authorized Official - Last Name:POPPLE
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:850-474-8724
Mailing Address - Street 1:8333 N DAVIS HWY
Mailing Address - Street 2:
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32514-6050
Mailing Address - Country:US
Mailing Address - Phone:850-478-8100
Mailing Address - Fax:850-474-8083
Practice Address - Street 1:8333 N DAVIS HWY
Practice Address - Street 2:
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32514-6050
Practice Address - Country:US
Practice Address - Phone:850-474-8000
Practice Address - Fax:850-474-8275
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-28
Last Update Date:2014-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CJ0195OtherRAILROAD MEDICARE
AL000810075Medicaid
FL00147OtherBLUE SHIELD
FL060060100Medicaid