1154773950 NPI number — EMERALD COAST INFECTIOUS DISEASES MEDICAL GROUP, PA

Table of content: (NPI 1154773950)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1154773950 NPI number — EMERALD COAST INFECTIOUS DISEASES MEDICAL GROUP, PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EMERALD COAST INFECTIOUS DISEASES MEDICAL GROUP, PA
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1154773950
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/03/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1620 W. NORTHWEST HWY
Provider Second Line Business Mailing Address:
SUITE 100
Provider Business Mailing Address City Name:
GRAPEVINE
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
76051
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
817-572-0009
Provider Business Mailing Address Fax Number:
817-572-0221

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
917 MAR WALT DRIVE
Provider Second Line Business Practice Location Address:
SUITE D
Provider Business Practice Location Address City Name:
FORT WALTON BEACH
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32547
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
850-312-3570
Provider Business Practice Location Address Fax Number:
850-312-3090
Provider Enumeration Date:
07/06/2016

Additional Information

Authorized Official

Authorized Official Last Name:
SQUATRITO
Authorized Official First Name:
ERIC
Authorized Official Middle Name:
Authorized Official Title or Position:
VICE PRESIDENT OF OPERATIONS
Authorized Official Telephone Number:
724-977-8498

Provider Taxonomy Codes

  • Taxonomy code: 333600000X , with the licence number:  PH30219 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336C0003X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1165528300 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2160919 . This is a "PK" identifier . This identifiers is of the category "OTHER".




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