=====================================================
General NPI Number Information
=====================================================
NPI Number | 1578388229
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | EMERALD COAST HEART & AFIB, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/18/2024
-----------------------------------------------------
Last Update Date | 01/22/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 550 REDSTONE AVE W STE 430
-----------------------------------------------------
City | CRESTVIEW
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32536-6457
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 850-602-0094
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 550 REDSTONE AVE W STE 430
-----------------------------------------------------
City | CRESTVIEW
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32536-6457
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 850-854-3278
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER, PHYSICIAN
-----------------------------------------------------
Name | IAN LANDON WEISBERG
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 850-854-3278
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RC0001X
-----------------------------------------------------
Taxonomy Name | Clinical Cardiac Electrophysiology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------