Provider Demographics
NPI:1962478230
Name:FLORIDA PANHANDLE PEDIATRIC FOUNDATION, INC.
Entity Type:Organization
Organization Name:FLORIDA PANHANDLE PEDIATRIC FOUNDATION, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROJECT ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:PATTI
Authorized Official - Middle Name:A
Authorized Official - Last Name:WELCH
Authorized Official - Suffix:
Authorized Official - Credentials:RN-BSN
Authorized Official - Phone:850-872-4840
Mailing Address - Street 1:2814 W 15TH ST
Mailing Address - Street 2:
Mailing Address - City:PANAMA CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32401-1376
Mailing Address - Country:US
Mailing Address - Phone:850-872-4840
Mailing Address - Fax:850-872-4468
Practice Address - Street 1:2814 W 15TH ST
Practice Address - Street 2:
Practice Address - City:PANAMA CITY
Practice Address - State:FL
Practice Address - Zip Code:32401-1376
Practice Address - Country:US
Practice Address - Phone:850-872-4840
Practice Address - Fax:850-872-4468
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-27
Last Update Date:2009-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
No251B00000XAgenciesCase Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL371185401Medicaid
FL371185400Medicaid