MEDICARE: EMERALD COAST UROLOGY

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	208800000X	Urology Physician	ME0043999	FL

General Provider Information

NPI Number	:	1891729026
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EMERALD COAST UROLOGY

Provider Business Mailing Address
First Line	:	909 MAR WALT DR
Second Line	:	SUITE 1011
City	:	FORT WALTON BEACH
State	:	FL
Zip	:	32547-6635
Country	:	US
Telephone Number	:	850-863-3377
Fax Number	:

Provider Business Practice Location Address
First Line	:	909 MAR WALT DR
Second Line	:	SUITE 1011
City	:	FORT WALTON BEACH
State	:	FL
Zip	:	32547-6635
Country	:	US
Telephone Number	:	850-863-3377
Fax Number	:

Authorized Official
Title or Position	:	OFFICE MANAGER
Name	:	LESLIE COOPER
Credential	:
Telephone Number	:	850-863-3377

Provider Enumeration Date	:	07/11/2006
Last Update Date	:	02/27/2008

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