Provider Demographics
NPI:1639128820
Name:FORT WALTON BEACH MEDICAL CENTER, INC.
Entity type:Organization
Organization Name:FORT WALTON BEACH MEDICAL CENTER, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:CAMILLE
Authorized Official - Middle Name:
Authorized Official - Last Name:HENRY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:850-862-1111
Mailing Address - Street 1:1000 MAR WALT DR
Mailing Address - Street 2:
Mailing Address - City:FT WALTON BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32547-6708
Mailing Address - Country:US
Mailing Address - Phone:850-862-1111
Mailing Address - Fax:850-862-9149
Practice Address - Street 1:1000 MAR WALT DR
Practice Address - Street 2:
Practice Address - City:FT WALTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:32547-6708
Practice Address - Country:US
Practice Address - Phone:850-862-1111
Practice Address - Fax:850-862-9149
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-08
Last Update Date:2025-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282N00000XHospitalsGeneral Acute Care Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC10354BMedicaid
ME1744034Medicaid
FL220304OtherAVMED
FL35871OtherAMERIGROUP
FL444OtherBLUE CROSS/HOPT
LA1744034Medicaid
ALFOR0223NMedicaid
AL010040OtherBLUE CROSS
NY01884660Medicaid
FL11132500Medicaid
CAXHSP32483Medicaid
GA000593788XMedicaid
TN100027853Medicaid
PA1503704Medicaid