Provider Demographics
NPI:1629114541
Name:BEACHES FAMILY PRACTICE CENTER
Entity Type:Organization
Organization Name:BEACHES FAMILY PRACTICE CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:ERNEST
Authorized Official - Middle Name:GEORGE
Authorized Official - Last Name:HASLAM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:850-234-8811
Mailing Address - Street 1:230 S HIGHWAY 79
Mailing Address - Street 2:
Mailing Address - City:PANAMA CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32413-2151
Mailing Address - Country:US
Mailing Address - Phone:850-234-8811
Mailing Address - Fax:850-234-8556
Practice Address - Street 1:230 S HIGHWAY 79
Practice Address - Street 2:
Practice Address - City:PANAMA CITY
Practice Address - State:FL
Practice Address - Zip Code:32413-2151
Practice Address - Country:US
Practice Address - Phone:850-234-8811
Practice Address - Fax:850-234-8556
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BEACHES FAMILY PRACTICE CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-01-29
Last Update Date:2008-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME26512174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL76011OtherBLUE CROSS
FL3806OtherFLORIDA MEDICARE
FLD58320Medicare UPIN
FL3806OtherFLORIDA MEDICARE