1689636458 NPI number — EMERALD COAST PATHOLOGY ASSOCIATES PA

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1689636458 NPI number — EMERALD COAST PATHOLOGY ASSOCIATES PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EMERALD COAST PATHOLOGY ASSOCIATES 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:
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:
1689636458
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/17/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 100559
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FLORENCE
Provider Business Mailing Address State Name:
SC
Provider Business Mailing Address Postal Code:
29501-0559
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
843-664-4300
Provider Business Mailing Address Fax Number:
843-664-4308

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1000 MAR WALT DR
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:
32547-6708
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
850-863-7660
Provider Business Practice Location Address Fax Number:
850-315-7808
Provider Enumeration Date:
04/05/2006

Additional Information

Authorized Official

Authorized Official Last Name:
BLANCHARD
Authorized Official First Name:
ROBERT
Authorized Official Middle Name:
NEIL
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
850-863-7660

Provider Taxonomy Codes

  • Taxonomy code: 207ZP0102X , with the licence number:  ME66117 , 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: 21346 . This is a "BCBS" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".




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