Provider Demographics
NPI:1649466137
Name:PANAMA CITY GENERAL SURGERY PA
Entity type:Organization
Organization Name:PANAMA CITY GENERAL SURGERY PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:A/R MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:SHARON
Authorized Official - Middle Name:K
Authorized Official - Last Name:BLAIR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:850-763-3039
Mailing Address - Street 1:806 E 6TH ST
Mailing Address - Street 2:
Mailing Address - City:PANAMA CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32401-3620
Mailing Address - Country:US
Mailing Address - Phone:850-763-6224
Mailing Address - Fax:850-872-1623
Practice Address - Street 1:806 E 6TH ST
Practice Address - Street 2:
Practice Address - City:PANAMA CITY
Practice Address - State:FL
Practice Address - Zip Code:32401-3620
Practice Address - Country:US
Practice Address - Phone:850-763-6224
Practice Address - Fax:850-872-1623
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-19
Last Update Date:2009-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL0044185174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1457310989OtherNIP
FL24920OtherMEDICARE PTAN NUMBER
FL068584400Medicaid
FL03619ZOtherMEDICARE PROVIDER NUMBER
FL068584400Medicaid