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General NPI Number Information
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NPI Number | 1891729026
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Entity Type | Organization
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Legal Business Name | EMERALD COAST UROLOGY
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Dates
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Enumeration Date | 07/11/2006
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Last Update Date | 02/27/2008
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Provider Practice Location Address
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Address Line | 909 MAR WALT DR SUITE 1011
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City | FORT WALTON BEACH
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State | FL
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Zip | 32547-6635
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Country | US
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Telephone | 850-863-3377
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Fax |
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Provider Business Mailing Address
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Address Line | 909 MAR WALT DR SUITE 1011
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City | FORT WALTON BEACH
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State | FL
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Zip | 32547-6635
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Country | US
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Telephone | 850-863-3377
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Fax |
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Authorized Official
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Title or Position | OFFICE MANAGER
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Name | LESLIE COOPER
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Credential |
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Telephone | 850-863-3377
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208800000X
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Taxonomy Name | Urology Physician
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License Number | ME0043999
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License Number State | FL
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