Provider Demographics
NPI:1952572158
Name:PACE BLVD FAMILY PRACTICE PA
Entity Type:Organization
Organization Name:PACE BLVD FAMILY PRACTICE PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:SAMUEL
Authorized Official - Middle Name:R
Authorized Official - Last Name:GREENLEE
Authorized Official - Suffix:II
Authorized Official - Credentials:MD
Authorized Official - Phone:850-435-8998
Mailing Address - Street 1:1500 N PACE BLVD
Mailing Address - Street 2:
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32505-6467
Mailing Address - Country:US
Mailing Address - Phone:850-435-8998
Mailing Address - Fax:850-435-8995
Practice Address - Street 1:1500 N PACE BLVD
Practice Address - Street 2:
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32505-6467
Practice Address - Country:US
Practice Address - Phone:850-435-8998
Practice Address - Fax:850-435-8995
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-14
Last Update Date:2008-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0058619261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
11483YMedicare UPIN
FLK1710Medicare PIN