Healthcare Provider Details

I. General information

NPI: 1508851569
Provider Name (Legal Business Name): SPACE COAST EMERGENCY PHYSICIANS PLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/15/2005
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

701 W COCOA BEACH CSWY
COCOA BEACH FL
32931-3585
US

IV. Provider business mailing address

PO BOX 918994
ORLANDO FL
32891-8994
US

V. Phone/Fax

Practice location:
  • Phone: 321-799-7111
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier94825
Identifier TypeOTHER
Identifier StateFL
Identifier IssuerBCBS GROUP
# 2
IdentifierDD1357
Identifier TypeOTHER
Identifier StateFL
Identifier IssuerRR MCR GROUP

VIII. Authorized Official

Name: DR. MICHAEL MCGOOHAN
Title or Position: PRESIDENT
Credential: DO
Phone: 866-396-6416