Basic Information
| Provider Information | |||||||||
| NPI: | 1750526398 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | EMERALD COAST EMERGENCY PHYSICIANS LLP | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 602162 | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282602162 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8669165259 | ||||||||
| FaxNumber: | 2319224030 | ||||||||
| Practice Location | |||||||||
| Address1: | 1000 MAR-WALT DRIVE | ||||||||
| Address2: | |||||||||
| City: | FORT WALTON BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 325476795 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8508621111 | ||||||||
| FaxNumber: | 8508629149 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/11/2008 | ||||||||
| LastUpdateDate: | 09/21/2009 | ||||||||
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| AuthorizedOfficialLastName: | KING | ||||||||
| AuthorizedOfficialFirstName: | DERIK | ||||||||
| AuthorizedOfficialMiddleName: | K | ||||||||
| AuthorizedOfficialTitleorPosition: | LLP MANAGING PARTNER | ||||||||
| AuthorizedOfficialTelephone: | 8669165259 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 72205 | 01 | FL | BLUE SHIELD | OTHER | 000625801 | 05 | FL | MEDICAID |