Provider Demographics
NPI:1710022827
Name:SEAGROVE BEACH MEDICAL CLINIC INC
Entity Type:Organization
Organization Name:SEAGROVE BEACH MEDICAL CLINIC INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:NORMAN
Authorized Official - Last Name:ROLL
Authorized Official - Suffix:
Authorized Official - Credentials:PA-C,MS,BA,BS,MPA
Authorized Official - Phone:850-231-6200
Mailing Address - Street 1:5399 E COUNTY HIGHWAY 30A
Mailing Address - Street 2:SUITE 5
Mailing Address - City:SANTA ROSA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32459-6717
Mailing Address - Country:US
Mailing Address - Phone:850-231-6200
Mailing Address - Fax:850-231-3500
Practice Address - Street 1:5399 E COUNTY HIGHWAY 30A
Practice Address - Street 2:SUITE 5
Practice Address - City:SANTA ROSA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32459-6717
Practice Address - Country:US
Practice Address - Phone:850-231-6200
Practice Address - Fax:850-231-3500
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-20
Last Update Date:2013-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA3191261QU0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL290446200Medicaid
FL97275OtherBLUE CROSS BLUS SHIELD
FLS69365Medicare UPIN
FL97275OtherBLUE CROSS BLUS SHIELD