Provider Demographics
NPI:1891763108
Name:EMERALD COAST RADIATION ONCOLOGY
Entity Type:Organization
Organization Name:EMERALD COAST RADIATION ONCOLOGY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO/SECRETARY/TREASURER
Authorized Official - Prefix:MR
Authorized Official - First Name:BUDDY
Authorized Official - Middle Name:
Authorized Official - Last Name:ELMORE
Authorized Official - Suffix:
Authorized Official - Credentials:CFO
Authorized Official - Phone:850-416-7638
Mailing Address - Street 1:PO BOX 18490
Mailing Address - Street 2:
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32523-8490
Mailing Address - Country:US
Mailing Address - Phone:850-622-0873
Mailing Address - Fax:850-622-1912
Practice Address - Street 1:7720 US HIGHWAY 98 W.
Practice Address - Street 2:SUITE 140
Practice Address - City:DESTIN
Practice Address - State:FL
Practice Address - Zip Code:32550-7230
Practice Address - Country:US
Practice Address - Phone:850-622-0873
Practice Address - Fax:850-622-1912
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-10
Last Update Date:2010-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation OncologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL267422000Medicaid
FL267422000-GROUPMedicaid
=========OtherTAX ID NUMBER
=========OtherTAX ID NUMBER
34450-GROUPMedicare PIN