Provider Demographics
NPI:1053392233
Name:CHILD NEUROLOGY CENTER OF NORTHWEST FLORIDA PA
Entity type:Organization
Organization Name:CHILD NEUROLOGY CENTER OF NORTHWEST FLORIDA PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:BEN
Authorized Official - Last Name:RENFROE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:850-932-5055
Mailing Address - Street 1:PO BOX 280
Mailing Address - Street 2:
Mailing Address - City:GULF BREEZE
Mailing Address - State:FL
Mailing Address - Zip Code:32562-0280
Mailing Address - Country:US
Mailing Address - Phone:850-932-5055
Mailing Address - Fax:850-932-1401
Practice Address - Street 1:400 GULF BREEZE PKWY
Practice Address - Street 2:SUITE 300
Practice Address - City:GULF BREEZE
Practice Address - State:FL
Practice Address - Zip Code:32561-4495
Practice Address - Country:US
Practice Address - Phone:850-932-5055
Practice Address - Fax:850-932-1401
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-07
Last Update Date:2025-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
No2084N0402XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology with Special Qualifications in Child NeurologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL529918930Medicaid
FL257889100Medicaid
FL257889100Medicaid