Provider Demographics
NPI:1922031343
Name:SURGICAL ASSOCIATES OF NORTHWEST FL PA
Entity Type:Organization
Organization Name:SURGICAL ASSOCIATES OF NORTHWEST FL PA
Other - Org Name:SURGICAL ASSOCIATES OF NORTHWEST FL PA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:BOULWARE
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:850-785-3232
Mailing Address - Street 1:740 HARRISON AVE
Mailing Address - Street 2:
Mailing Address - City:PANAMA CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32401-2524
Mailing Address - Country:US
Mailing Address - Phone:850-785-3232
Mailing Address - Fax:850-747-8648
Practice Address - Street 1:740 HARRISON AVE
Practice Address - Street 2:
Practice Address - City:PANAMA CITY
Practice Address - State:FL
Practice Address - Zip Code:32401-2524
Practice Address - Country:US
Practice Address - Phone:850-785-3232
Practice Address - Fax:850-747-8648
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-09
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLNOT APPLICABLE208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL00874Medicare ID - Type UnspecifiedGROUP PROVIDER NUMBER