# INDIVIDUAL PROVIDER

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- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1376890293
- **Authorized official:** DR. CHUONG NGUYEN THAI M.D. (MAJOR)
- **Authorized official phone:** (850) 883-9055

## Contact information

- **Practice address:** 307 BOATNER ROAD SUITE 114, 96TH MEDICAL GROUP, EGLIN, FL 32542
- **Practice address phone:** (850) 883-8600
- **Mailing address:** 307 BOATNER ROAD SUITE 114, 96TH MEDICAL GROUP, EGLIN, FL 32542
- **Mailing address phone:** (850) 883-8600

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 286500000X | Military Hospital | — | NULL | Yes |

## Other

- **Enumeration date:** 08/09/2012
- **Last updated:** 09/14/2012