Provider Demographics
NPI:1205887650
Name:SACRED HEART MEDICAL GRP AT DESTIN
Entity type:Organization
Organization Name:SACRED HEART MEDICAL GRP AT DESTIN
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ENROLLMENT SPECIALIST
Authorized Official - Prefix:MRS
Authorized Official - First Name:JAN
Authorized Official - Middle Name:
Authorized Official - Last Name:FOLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:850-475-4620
Mailing Address - Street 1:PO BOX 2699
Mailing Address - Street 2:HEALTHPLAN ENROLLMENT
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32513-2699
Mailing Address - Country:US
Mailing Address - Phone:850-475-4620
Mailing Address - Fax:850-416-4619
Practice Address - Street 1:4451 BAYOU BLVD
Practice Address - Street 2:
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32503-2601
Practice Address - Country:US
Practice Address - Phone:850-475-4500
Practice Address - Fax:850-475-4771
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-12
Last Update Date:2012-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLK6407Medicare PIN