Provider Demographics
NPI:1114013018
Name:EMERALD COAST PULMONOLOGY, PA
Entity Type:Organization
Organization Name:EMERALD COAST PULMONOLOGY, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:LAURIE
Authorized Official - Middle Name:
Authorized Official - Last Name:KOSZUTA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:850-423-1311
Mailing Address - Street 1:502 E HICKORY AVE
Mailing Address - Street 2:
Mailing Address - City:CRESTVIEW
Mailing Address - State:FL
Mailing Address - Zip Code:32536-2742
Mailing Address - Country:US
Mailing Address - Phone:850-423-1311
Mailing Address - Fax:850-423-1313
Practice Address - Street 1:502 E HICKORY AVE
Practice Address - Street 2:
Practice Address - City:CRESTVIEW
Practice Address - State:FL
Practice Address - Zip Code:32536-2742
Practice Address - Country:US
Practice Address - Phone:850-423-1311
Practice Address - Fax:850-423-1313
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-05
Last Update Date:2011-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME63871207RC0200X, 207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary DiseaseGroup - Multi-Specialty
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL28192Medicare ID - Type Unspecified