Provider Demographics
NPI:1891729026
Name:EMERALD COAST UROLOGY
Entity Type:Organization
Organization Name:EMERALD COAST UROLOGY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:LESLIE
Authorized Official - Middle Name:
Authorized Official - Last Name:COOPER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:850-863-3377
Mailing Address - Street 1:909 MAR WALT DR
Mailing Address - Street 2:SUITE 1011
Mailing Address - City:FORT WALTON BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32547-6635
Mailing Address - Country:US
Mailing Address - Phone:850-863-3377
Mailing Address - Fax:
Practice Address - Street 1:909 MAR WALT DR
Practice Address - Street 2:SUITE 1011
Practice Address - City:FORT WALTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:32547-6635
Practice Address - Country:US
Practice Address - Phone:850-863-3377
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-11
Last Update Date:2008-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0043999208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLC78505Medicare UPIN
47173Medicare ID - Type Unspecified