Provider Demographics
NPI:1144022146
Name:BEACHSIDE MEDICAL GROUP LLC
Entity type:Organization
Organization Name:BEACHSIDE MEDICAL GROUP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:EVIE
Authorized Official - Middle Name:
Authorized Official - Last Name:DUCKWORTH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:850-478-1312
Mailing Address - Street 1:4951 GRANDE DR
Mailing Address - Street 2:
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32504-8965
Mailing Address - Country:US
Mailing Address - Phone:850-478-1312
Mailing Address - Fax:850-473-0500
Practice Address - Street 1:123 BAPTIST WAY
Practice Address - Street 2:
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32503-2254
Practice Address - Country:US
Practice Address - Phone:850-478-1312
Practice Address - Fax:850-473-0500
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-03-27
Last Update Date:2025-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080N0001XAllopathic & Osteopathic PhysiciansPediatricsNeonatal-Perinatal MedicineGroup - Single Specialty