Healthcare Provider Details

I. General information

NPI: 1427144153
Provider Name (Legal Business Name): EMERALD COAST PEDIATRICS P.A.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/04/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5834 BERRYHILL RD
MILTON FL
32570-8275
US

IV. Provider business mailing address

5834 BERRYHILL RD
MILTON FL
32570-8275
US

V. Phone/Fax

Practice location:
  • Phone: 850-623-5437
  • Fax: 850-626-7803
Mailing address:
  • Phone: 850-623-5437
  • Fax: 850-626-7803

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberME55036
License Number StateFL

VIII. Authorized Official

Name: DR. JOHN A VANOSTENBRIDGE
Title or Position: PRESIDENT
Credential: M.D.
Phone: 850-623-5437