Provider Demographics
NPI:1881674257
Name:FIRST PHYSICIANS GROUP PA
Entity Type:Organization
Organization Name:FIRST PHYSICIANS GROUP PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING
Authorized Official - Prefix:
Authorized Official - First Name:KYLIE
Authorized Official - Middle Name:
Authorized Official - Last Name:BAISDEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:850-994-5660
Mailing Address - Street 1:PO BOX 18868
Mailing Address - Street 2:
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32523-8868
Mailing Address - Country:US
Mailing Address - Phone:850-994-5660
Mailing Address - Fax:859-994-5841
Practice Address - Street 1:3802 HIGHWAY 90
Practice Address - Street 2:
Practice Address - City:PACE
Practice Address - State:FL
Practice Address - Zip Code:32571-1014
Practice Address - Country:US
Practice Address - Phone:850-994-5660
Practice Address - Fax:850-994-5841
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-20
Last Update Date:2009-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL261372508Medicaid
FL261372505Medicaid
FL261372506Medicaid
FL263172510Medicaid
FL608177300OtherUS DEPARTMENT OF LABOR
FLCA7660OtherRAILROAD MEDICARE
FL0582OtherHEALTHY KIDS
FL263172501Medicaid
FL38502OtherBLUE CROSS BLUE SHIELD FL
FL261372500Medicaid
FL261372502Medicaid
FL261372509Medicaid
FL263172503Medicaid
FL0582OtherHEALTH OPTIONS
FL261372507Medicaid
FL261372507Medicaid