Provider Demographics
NPI:1750717195
Name:FORKED DEER RIVER INPATIENT SERVICES, PLLC
Entity type:Organization
Organization Name:FORKED DEER RIVER INPATIENT SERVICES, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:KATHY
Authorized Official - Middle Name:
Authorized Official - Last Name:KONDAS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:973-251-1132
Mailing Address - Street 1:815 S PALAFOX ST
Mailing Address - Street 2:3RD FLOOR
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32502-5960
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:400 E TICKLE ST
Practice Address - Street 2:
Practice Address - City:DYERSBURG
Practice Address - State:TN
Practice Address - Zip Code:38024-3120
Practice Address - Country:US
Practice Address - Phone:731-285-2410
Practice Address - Fax:800-305-3233
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-09-17
Last Update Date:2020-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty