MEDICARE: EMERALD COAST INFECTIOUS DISEASES MEDICAL GROUP, P.A.

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	332BC3200X	Customized Equipment (DME)
2	332B00000X	Durable Medical Equipment & Medical Supplies

General Provider Information

NPI Number	:	1639978356
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EMERALD COAST INFECTIOUS DISEASES MEDICAL GROUP, P.A.

Provider Business Mailing Address
First Line	:	917 MAR WALT DR
Second Line	:
City	:	FORT WALTON BEACH
State	:	FL
Zip	:	32547-6651
Country	:	US
Telephone Number	:	850-862-3979
Fax Number	:

Provider Business Practice Location Address
First Line	:	1326 LEWIS TURNER BLVD
Second Line	:
City	:	FORT WALTON BEACH
State	:	FL
Zip	:	32547-1139
Country	:	US
Telephone Number	:	850-855-4048
Fax Number	:

Authorized Official
Title or Position	:	ASSISTANT PRACTICE MANAGER
Name	:	KELLEY GEAR
Credential	:
Telephone Number	:	850-862-3979

Provider Enumeration Date	:	03/13/2025
Last Update Date	:	03/13/2025

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