Provider Demographics
NPI:1255398228
Name:PANHANDLE RURAL HEALTH INCORPORATED
Entity type:Organization
Organization Name:PANHANDLE RURAL HEALTH INCORPORATED
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER SUPERVISING PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:CLEATIOUS
Authorized Official - Middle Name:DAVID
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:I
Authorized Official - Credentials:MD
Authorized Official - Phone:850-675-4546
Mailing Address - Street 1:PO BOX 10
Mailing Address - Street 2:
Mailing Address - City:JAY
Mailing Address - State:FL
Mailing Address - Zip Code:32565-0010
Mailing Address - Country:US
Mailing Address - Phone:850-675-4546
Mailing Address - Fax:850-675-4548
Practice Address - Street 1:14088 ALABAMA ST
Practice Address - Street 2:
Practice Address - City:JAY
Practice Address - State:FL
Practice Address - Zip Code:32565-1036
Practice Address - Country:US
Practice Address - Phone:850-675-4546
Practice Address - Fax:850-675-4548
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-26
Last Update Date:2012-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL660022102Medicaid
FL21333OtherBCBS OF FLORIDA GROUP NUMBER
FL660022100Medicaid
FL21333OtherBCBS OF FLORIDA GROUP NUMBER