Basic Information
| Provider Information | |||||||||
| NPI: | 1104875699 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | FORT WALTON BEACH MEDICAL CENTER, INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | FORT WALTON BEACH MEDICAL CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1000 MAR WALT DR | ||||||||
| Address2: | |||||||||
| City: | FT WALTON BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 325476708 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8508621111 | ||||||||
| FaxNumber: | 8508629149 | ||||||||
| Practice Location | |||||||||
| Address1: | 1000 MAR WALT DR | ||||||||
| Address2: | |||||||||
| City: | FT WALTON BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 325476708 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8508621111 | ||||||||
| FaxNumber: | 8508629149 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/10/2006 | ||||||||
| LastUpdateDate: | 03/30/2022 | ||||||||
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| AuthorizedOfficialLastName: | MOORE | ||||||||
| AuthorizedOfficialFirstName: | STEVE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 8503151358 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 03/30/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282N00000X | Y | Hospitals | General Acute Care Hospital |
ID Information
| ID | Type | State | Issuer | Description | XHSP42482 | 05 | CA | MEDICAID |