MEDICARE: EMERALD COAST INTERNAL MEDICINE AND GERIATRICS LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207RG0300X	Geriatric Medicine (Internal Medicine) Physician	ME114732	FL

General Provider Information

NPI Number	:	1114339074
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EMERALD COAST INTERNAL MEDICINE AND GERIATRICS LLC

Provider Business Mailing Address
First Line	:	PO BOX 419
Second Line	:
City	:	LYNN HAVEN
State	:	FL
Zip	:	32444-0419
Country	:	US
Telephone Number	:	850-896-9688
Fax Number	:	850-769-7717

Provider Business Practice Location Address
First Line	:	280 FOREST PARK CIR
Second Line	:
City	:	PANAMA CITY
State	:	FL
Zip	:	32405-4919
Country	:	US
Telephone Number	:	850-896-9688
Fax Number	:	850-769-7717

Authorized Official
Title or Position	:	MEDICAL DOCTOR
Name	:	DR. EMAD A EISA
Credential	:	M.D.
Telephone Number	:	703-598-6013

Provider Enumeration Date	:	05/27/2014
Last Update Date	:	09/24/2014

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