Basic Information
| Provider Information | |||||||||
| NPI: | 1518973908 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | 96TH MDG EGLIN AFB | ||||||||
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| Mailing Information | |||||||||
| Address1: | 895 SANTA ROSA BLVD APT 312 | ||||||||
| Address2: | |||||||||
| City: | FORT WALTON BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 325481907 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 1000 MAR WALT DR | ||||||||
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| City: | FORT WALTON BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 325476708 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8508621111 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/31/2006 | ||||||||
| LastUpdateDate: | 06/13/2008 | ||||||||
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| AuthorizedOfficialLastName: | HOLT | ||||||||
| AuthorizedOfficialFirstName: | ERIC | ||||||||
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| AuthorizedOfficialTitleorPosition: | STAFF ANESTHESIOLOGIST | ||||||||
| AuthorizedOfficialTelephone: | 6178408249 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 286500000X | 02002895A | IN | Y | Hospitals | Military Hospital |
No ID Information.