Provider Demographics
NPI:1013054469
Name:WHITE-WILSON MEDICAL CENTER, P.A.
Entity Type:Organization
Organization Name:WHITE-WILSON MEDICAL CENTER, P.A.
Other - Org Name:WHITE WILSON MED CTR-BWB FP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DOUGLAS
Authorized Official - Middle Name:W
Authorized Official - Last Name:RIGBY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:850-863-8150
Mailing Address - Street 1:1005 MAR WALT DR
Mailing Address - Street 2:BUSINESS OFFICE
Mailing Address - City:FORT WALTON BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32547-6707
Mailing Address - Country:US
Mailing Address - Phone:850-863-8105
Mailing Address - Fax:850-863-8548
Practice Address - Street 1:2001 E HIGHWAY 20
Practice Address - Street 2:FAMILY PRACTICE DEPARTMENT
Practice Address - City:NICEVILLE
Practice Address - State:FL
Practice Address - Zip Code:32578-8826
Practice Address - Country:US
Practice Address - Phone:850-897-4400
Practice Address - Fax:850-897-0623
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-01
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL059722804Medicaid