Healthcare Provider Details

I. General information

NPI: 1457150179
Provider Name (Legal Business Name): EMERALD COAST INFECTIOUS DISEASES MEDICAL GROUP, P.A.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/13/2025
Last Update Date: 03/13/2025
Certification Date: 02/27/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1710 LISENBY AVE
PANAMA CITY FL
32405-3730
US

IV. Provider business mailing address

917 MAR WALT DR
FORT WALTON BEACH FL
32547-6651
US

V. Phone/Fax

Practice location:
  • Phone: 850-807-4420
  • Fax:
Mailing address:
  • Phone: 850-862-3979
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332BC3200X
TaxonomyCustomized Equipment (DME)
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State

VIII. Authorized Official

Name: KELLEY GEAR
Title or Position: ASSISTANT PRACTICE MANAGER
Credential:
Phone: 850-862-3979