Provider Demographics
NPI:1750480380
Name:TALLAHASSEE GYN-ONCOLOGY LLC
Entity Type:Organization
Organization Name:TALLAHASSEE GYN-ONCOLOGY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:MICKEY
Authorized Official - Middle Name:S
Authorized Official - Last Name:PICKLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:850-523-2117
Mailing Address - Street 1:PO BOX 100196
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30384-0196
Mailing Address - Country:US
Mailing Address - Phone:808-780-5134
Mailing Address - Fax:850-784-7706
Practice Address - Street 1:2770 CAPITAL MEDICAL BLVD
Practice Address - Street 2:SUITE 210
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32308-8417
Practice Address - Country:US
Practice Address - Phone:850-877-7392
Practice Address - Fax:850-877-1535
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-21
Last Update Date:2008-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME96687207VX0201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207VX0201XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecologic OncologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLAC195Medicare PIN