Basic Information
| Provider Information | |||||||||
| NPI: | 1760432900 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SACRED HEART HOSPITAL ON THE EMERALD COAST | ||||||||
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| OtherOrganizationName: | SACRED HEART MEDICAL GROUP DESTIN | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2699 | ||||||||
| Address2: | HEALTHPLAN ENROLLMENT | ||||||||
| City: | PENSACOLA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 325132699 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8504754620 | ||||||||
| FaxNumber: | 8504754619 | ||||||||
| Practice Location | |||||||||
| Address1: | 4451 BAYOU BLVD | ||||||||
| Address2: | |||||||||
| City: | PENSACOLA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 325032601 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8504754500 | ||||||||
| FaxNumber: | 8504754771 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/10/2006 | ||||||||
| LastUpdateDate: | 04/11/2012 | ||||||||
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| AuthorizedOfficialLastName: | FOLEY | ||||||||
| AuthorizedOfficialFirstName: | JAN | ||||||||
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| AuthorizedOfficialTitleorPosition: | HPE SPECIALIST | ||||||||
| AuthorizedOfficialTelephone: | 8504754620 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | 207Q00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 207RC0000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
No ID Information.