1437114378 NPI number — EMERALD COAST SURGERY CENTER, LP

Table of content: (NPI 1437114378)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1437114378 NPI number — EMERALD COAST SURGERY CENTER, LP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EMERALD COAST SURGERY CENTER, LP
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:
EMERALD COAST SURGERY CENTER
Provider Other Organization Name Type Code:
3
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:
1437114378
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/27/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
995 MAR WALT DRIVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FORT WALTON BEACH
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32547
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
850-863-7887
Provider Business Mailing Address Fax Number:
850-863-6645

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
995 MAR WALT DRIVE
Provider Second Line Business Practice Location Address:
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:
850-863-7887
Provider Business Practice Location Address Fax Number:
850-863-6645
Provider Enumeration Date:
04/20/2006

Additional Information

Authorized Official

Authorized Official Last Name:
KACHELHOFFER
Authorized Official First Name:
ANNE
Authorized Official Middle Name:
Authorized Official Title or Position:
ADMINISTRATOR
Authorized Official Telephone Number:
850-863-8165

Provider Taxonomy Codes

  • Taxonomy code: 261QA1903X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QA1903X , with the licence number: 996 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0791423 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 116206900 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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