Provider Demographics
NPI:1659541340
Name:SOUTH WALTON MEDICAL CENTER INC
Entity Type:Organization
Organization Name:SOUTH WALTON MEDICAL CENTER INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:RONALD
Authorized Official - Middle Name:BRUCE
Authorized Official - Last Name:CAUSTON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:850-837-8005
Mailing Address - Street 1:10005C US HIGHWAY 98 W
Mailing Address - Street 2:
Mailing Address - City:DESTIN
Mailing Address - State:FL
Mailing Address - Zip Code:32550-4962
Mailing Address - Country:US
Mailing Address - Phone:850-837-8005
Mailing Address - Fax:850-837-4352
Practice Address - Street 1:10005C US HIGHWAY 98 W
Practice Address - Street 2:
Practice Address - City:DESTIN
Practice Address - State:FL
Practice Address - Zip Code:32550-4962
Practice Address - Country:US
Practice Address - Phone:850-837-8005
Practice Address - Fax:850-837-4352
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-10
Last Update Date:2009-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLFLME43330261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL265468700Medicaid
FL46168OtherBC BS
FL46168OtherBC BS