Provider Demographics
NPI:1114339074
Name:EMERALD COAST INTERNAL MEDICINE AND GERIATRICS LLC
Entity Type:Organization
Organization Name:EMERALD COAST INTERNAL MEDICINE AND GERIATRICS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:EMAD
Authorized Official - Middle Name:A
Authorized Official - Last Name:EISA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:703-598-6013
Mailing Address - Street 1:PO BOX 419
Mailing Address - Street 2:
Mailing Address - City:LYNN HAVEN
Mailing Address - State:FL
Mailing Address - Zip Code:32444-0419
Mailing Address - Country:US
Mailing Address - Phone:850-896-9688
Mailing Address - Fax:850-769-7717
Practice Address - Street 1:280 FOREST PARK CIR
Practice Address - Street 2:
Practice Address - City:PANAMA CITY
Practice Address - State:FL
Practice Address - Zip Code:32405-4919
Practice Address - Country:US
Practice Address - Phone:850-896-9688
Practice Address - Fax:850-769-7717
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-05-27
Last Update Date:2014-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME114732207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric MedicineGroup - Single Specialty