Basic Information
| Provider Information | |||||||||
| NPI: | 1265403729 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CMS PENSACOLA | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | FL DEPT OF HEALTH CMS PENSACOLA | ||||||||
| OtherOrganizationType: | 5 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
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| OtherNamePrefix: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 5192 BAYOU BLVD | ||||||||
| Address2: | |||||||||
| City: | PENSACOLA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 325032102 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8504845040 | ||||||||
| FaxNumber: | 8504755507 | ||||||||
| Practice Location | |||||||||
| Address1: | 5192 BAYOU BLVD | ||||||||
| Address2: | |||||||||
| City: | PENSACOLA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 325032102 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8504845040 | ||||||||
| FaxNumber: | 8504755507 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/31/2006 | ||||||||
| LastUpdateDate: | 04/19/2013 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | GASTON | ||||||||
| AuthorizedOfficialFirstName: | JEAN | ||||||||
| AuthorizedOfficialMiddleName: | DIANE | ||||||||
| AuthorizedOfficialTitleorPosition: | PROGRAM ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 8504845040 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251K00000X | Y | Agencies | Public Health or Welfare |
ID Information
| ID | Type | State | Issuer | Description | 052490500 | 05 | FL | MEDICAID |