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General NPI Number Information
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NPI Number | 1750565768
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Entity Type | Organization
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Legal Business Name | EMERALD COAST SURGICAL SPECIALISTS PA
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Dates
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Enumeration Date | 12/27/2007
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Last Update Date | 05/30/2008
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Provider Practice Location Address
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Address Line | 5992 BERRYHILL ROAD 203
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City | MILTON
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State | FL
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Zip | 32570
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Country | US
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Telephone | 850-626-2131
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Fax | 850-626-2133
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Provider Business Mailing Address
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Address Line | PO BOX 30215
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City | PENSACOLA
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State | FL
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Zip | 32503-1215
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Country | US
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Telephone | 850-626-2131
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Fax | 850-626-2133
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Authorized Official
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Title or Position | OWNER/PHYSICIAN
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Name | RANDALL L MCKISSACK
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Credential | MD
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Telephone | 850-626-2131
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208600000X
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Taxonomy Name | Surgery Physician
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License Number |
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License Number State |
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