Provider Demographics
NPI:1740429679
Name:NORTHWEST FLORIDA PRIMARY CARE LLC
Entity type:Organization
Organization Name:NORTHWEST FLORIDA PRIMARY CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:MARK
Authorized Official - Last Name:RODKEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:850-523-3816
Mailing Address - Street 1:2000 HEALTH PARK DR
Mailing Address - Street 2:
Mailing Address - City:BRENTWOOD
Mailing Address - State:TN
Mailing Address - Zip Code:37027-4525
Mailing Address - Country:US
Mailing Address - Phone:615-372-5426
Mailing Address - Fax:866-831-4898
Practice Address - Street 1:4400 E HIGHWAY 20 STE 203
Practice Address - Street 2:
Practice Address - City:NICEVILLE
Practice Address - State:FL
Practice Address - Zip Code:32578-7700
Practice Address - Country:US
Practice Address - Phone:850-897-3678
Practice Address - Fax:850-897-3708
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-02-17
Last Update Date:2017-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLBR218AMedicare PIN