Provider Demographics
NPI:1285726091
Name:EMERALD COAST NEONATOLOGY PA
Entity type:Organization
Organization Name:EMERALD COAST NEONATOLOGY PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DOUGLAS
Authorized Official - Middle Name:
Authorized Official - Last Name:SPRAGUE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:850-265-9332
Mailing Address - Street 1:PO BOX 15789
Mailing Address - Street 2:
Mailing Address - City:PANAMA CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32406
Mailing Address - Country:US
Mailing Address - Phone:850-265-9332
Mailing Address - Fax:850-784-7706
Practice Address - Street 1:4250 HOSPITAL DRIVE
Practice Address - Street 2:
Practice Address - City:MARIANNA
Practice Address - State:FL
Practice Address - Zip Code:32446
Practice Address - Country:US
Practice Address - Phone:850-265-9332
Practice Address - Fax:850-784-7706
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-29
Last Update Date:2009-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME668202080P0203X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080P0203XAllopathic & Osteopathic PhysiciansPediatricsPediatric Critical Care MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL45706OtherBCBS FLORIDA
FL260912600Medicaid
FL260912600Medicaid