NPIMap

Organization Active NPI

Ketchum Wood & Burgert Chartered DRS Ketchum Wood & Burgert

  • Anatomic Pathology & Clinical Pathology Physician
  • Tallahassee, FL
National Provider Identifier
1821060898
Registry record updated May 15, 2020
On this page

Key facts

NPPES NPI Registry
Primary specialty
Anatomic Pathology & Clinical Pathology PhysicianTaxonomy code 207ZP0102X
License
800000042 Issued in FL
Legal business name
KETCHUM WOOD & BURGERT CHARTERED DRS KETCHUM WOOD & BURGERT
Practice address
1899 Eider CT
Tallahassee, FL 32308-4537
Phone
(850) 878-5143
Fax
(850) 942-6622
NPI assigned
Feb 3, 2006
Last updated
May 15, 2020By the provider in NPPES
Organization subpart
Yes
Parent organization
KETCHUM WOOD & BURGERT CHARTERED DRS KETCHUM WOOD & BURGERTAs reported in NPPES

NPPES NPI Registry

Updated by the provider on May 15, 2020

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Mrs. Angela Fuqua
Title
Administrator
Phone
(850) 219-7603

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Anatomic Pathology & Clinical Pathology PhysicianGroup: 193400000X MULTIPLE SINGLE SPECIALTY GROUP 207ZP0102X 800000042 FL Primary

Addresses

Primary practice location

1899 Eider CT
Tallahassee, FL 32308-4537

Mailing address

1899 Eider CT
Tallahassee, FL 32308-4537
Phone (850) 878-5143

Other identifiers 3

IdentifierTypeStateIssuer
CF6643OtherFLRAILROAD MEDICARE
030063201MedicaidFL
00018OtherFLBC/BS HOSPITAL BASED SERV

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in FL

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20070926000270 FL Part B Supplier - Clinic/Group Practice 4082708755 Receives reassigned benefits from 10 practitioners
Practice locations: Tallahassee, FL; Panama City, FL; Marianna, FL; Perry, FL

Other NPIs with the same Medicare PAC ID 1

NPIs whose Medicare enrollments share a PECOS associate control ID (the same enrolled entity).

National Provider Directory

National Provider Directory
Tax ID family
Ketchum Wood Burgert Chart2 organizations share this tax ID, including this one
Part of
Ketchum Wood Burgert Chart

Other organizations with this tax ID 1

Organizations that report the same tax identification number in the National Provider Directory.

Locations

1600 Jenks Ave
Ste 4
Panama City, FL 32405
Phone (850) 878-5143

Ownership & related parties

Parent organization (reported in NPPES) 1

This organization reports itself as a subpart in NPPES; the parent’s legal name matches this organization in the same state.

Practitioners & affiliated clinicians

Practitioners 12

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1138924800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1589500800000",
    "number": "1821060898",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1899 EIDER CT",
            "city": "TALLAHASSEE",
            "state": "FL",
            "postal_code": "323084537",
            "telephone_number": "850-878-5143",
            "fax_number": "850-942-6622"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1899 EIDER CT",
            "city": "TALLAHASSEE",
            "state": "FL",
            "postal_code": "323084537",
            "telephone_number": "850-878-5143",
            "fax_number": "850-942-6622"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "KETCHUM WOOD & BURGERT CHARTERED DRS KETCHUM WOOD & BURGERT",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "KETCHUM WOOD & BURGERT CHARTERED DRS KETCHUM WOOD & BURGERT",
        "enumeration_date": "2006-02-03",
        "last_updated": "2020-05-15",
        "certification_date": "2020-05-15",
        "status": "A",
        "authorized_official_last_name": "FUQUA",
        "authorized_official_first_name": "ANGELA",
        "authorized_official_title_or_position": "ADMINISTRATOR",
        "authorized_official_telephone_number": "850-219-7603",
        "authorized_official_name_prefix": "Mrs."
    },
    "taxonomies": [
        {
            "code": "207ZP0102X",
            "taxonomy_group": "193400000X MULTIPLE SINGLE SPECIALTY GROUP",
            "desc": "Pathology, Anatomic Pathology & Clinical Pathology",
            "state": "FL",
            "license": "800000042",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "RAILROAD MEDICARE",
            "identifier": "CF6643",
            "state": "FL"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "030063201",
            "state": "FL"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "BC/BS HOSPITAL BASED SERV",
            "identifier": "00018",
            "state": "FL"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Tallahassee, FL

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on May 15, 2020; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.