Provider Demographics
NPI:1184140683
Name:LIVE OAK NEUROSURGICAL ASSOCIATES PLLC
Entity type:Organization
Organization Name:LIVE OAK NEUROSURGICAL ASSOCIATES PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:L
Authorized Official - Last Name:WOLFF
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:850-890-7706
Mailing Address - Street 1:PO BOX 2243
Mailing Address - Street 2:
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32513-2243
Mailing Address - Country:US
Mailing Address - Phone:850-478-1312
Mailing Address - Fax:850-474-9060
Practice Address - Street 1:8333 N DAVIS HWY FL 10
Practice Address - Street 2:
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32514
Practice Address - Country:US
Practice Address - Phone:850-512-3482
Practice Address - Fax:850-969-2130
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-08-16
Last Update Date:2018-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL022217200Medicaid
FLQYYRSOtherFLORIDA BLUE