Provider Demographics
NPI:1801294962
Name:DESTIN PULMONARY CRITICAL CARE, PLLC
Entity type:Organization
Organization Name:DESTIN PULMONARY CRITICAL CARE, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING SUPERVISOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:PANDRA
Authorized Official - Middle Name:MAE
Authorized Official - Last Name:YERBY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:850-608-6288
Mailing Address - Street 1:249 MACK BAYOU LOOP STE 201
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32459-7197
Mailing Address - Country:US
Mailing Address - Phone:850-608-6288
Mailing Address - Fax:850-608-6236
Practice Address - Street 1:249 MACK BAYOU LOOP STE 201
Practice Address - Street 2:
Practice Address - City:SANTA ROSA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32459-7197
Practice Address - Country:US
Practice Address - Phone:850-608-6288
Practice Address - Fax:850-608-6236
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-12-05
Last Update Date:2018-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care MedicineGroup - Single Specialty
No207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL014076700Medicaid