Provider Demographics
NPI:1396148292
Name:EMERALD COAST CENTER FOR NEUROLOGICAL DISORDERS
Entity type:Organization
Organization Name:EMERALD COAST CENTER FOR NEUROLOGICAL DISORDERS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ANTONETTE
Authorized Official - Middle Name:
Authorized Official - Last Name:MITCHEM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:850-438-1136
Mailing Address - Street 1:1110 AIRPORT BLVD
Mailing Address - Street 2:STE B
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32504-8649
Mailing Address - Country:US
Mailing Address - Phone:850-438-1136
Mailing Address - Fax:850-438-1148
Practice Address - Street 1:1110 AIRPORT BLVD
Practice Address - Street 2:STE B
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32504-8649
Practice Address - Country:US
Practice Address - Phone:850-438-1136
Practice Address - Fax:850-438-1148
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-10-06
Last Update Date:2024-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332900000XSuppliersNon-Pharmacy Dispensing Site
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL275377400Medicaid
I59103Medicare UPIN