Provider Demographics
NPI:1891765947
Name:MAHAN MEDICAL WALK IN
Entity Type:Organization
Organization Name:MAHAN MEDICAL WALK IN
Other - Org Name:WILTON R KANE MD
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/MD
Authorized Official - Prefix:
Authorized Official - First Name:WILTON
Authorized Official - Middle Name:R
Authorized Official - Last Name:KANE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:850-877-7164
Mailing Address - Street 1:1705 E MANAN DRIVE
Mailing Address - Street 2:
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32308
Mailing Address - Country:US
Mailing Address - Phone:850-877-7164
Mailing Address - Fax:850-656-1391
Practice Address - Street 1:1705 E MANAN DRIVE
Practice Address - Street 2:
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32308
Practice Address - Country:US
Practice Address - Phone:850-877-7164
Practice Address - Fax:850-656-1391
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-23
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME7902207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL99391OtherBCBS FL
FL99391OtherBCBS FL
D57099Medicare UPIN