Provider Demographics
NPI:1912928896
Name:FT WALTON BEACH INTERNAL MEDICINE LLC
Entity Type:Organization
Organization Name:FT WALTON BEACH INTERNAL MEDICINE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP
Authorized Official - Prefix:
Authorized Official - First Name:MICKEY
Authorized Official - Middle Name:
Authorized Official - Last Name:PICKLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:850-523-2117
Mailing Address - Street 1:1032 MAR WALT DR
Mailing Address - Street 2:SUITE 230
Mailing Address - City:FORT WALTON BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32547-6645
Mailing Address - Country:US
Mailing Address - Phone:850-862-0318
Mailing Address - Fax:850-862-2887
Practice Address - Street 1:1032 MAR WALT DR
Practice Address - Street 2:SUITE 230
Practice Address - City:FORT WALTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:32547-6645
Practice Address - Country:US
Practice Address - Phone:850-862-0318
Practice Address - Fax:850-862-2887
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-23
Last Update Date:2008-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLDH1185Medicare PIN