Provider Demographics
NPI:1184173338
Name:PANHANDLE SURGICAL SERVICES
Entity type:Organization
Organization Name:PANHANDLE SURGICAL SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:DOTTIE
Authorized Official - Middle Name:
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:850-640-3320
Mailing Address - Street 1:2202 STATE AVE
Mailing Address - Street 2:STE 104
Mailing Address - City:PANAMA CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32405-7601
Mailing Address - Country:US
Mailing Address - Phone:850-640-3320
Mailing Address - Fax:
Practice Address - Street 1:2202 STATE AVE
Practice Address - Street 2:STE 104
Practice Address - City:PANAMA CITY
Practice Address - State:FL
Practice Address - Zip Code:32405-7601
Practice Address - Country:US
Practice Address - Phone:850-640-3320
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-09-29
Last Update Date:2017-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME102627208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1528213394OtherINDIVIDUAL PROVIDER NPI