Provider Demographics
NPI:1750565768
Name:EMERALD COAST SURGICAL SPECIALISTS PA
Entity type:Organization
Organization Name:EMERALD COAST SURGICAL SPECIALISTS PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:RANDALL
Authorized Official - Middle Name:L
Authorized Official - Last Name:MCKISSACK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:850-626-2131
Mailing Address - Street 1:PO BOX 30215
Mailing Address - Street 2:
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32503-1215
Mailing Address - Country:US
Mailing Address - Phone:850-626-2131
Mailing Address - Fax:850-626-2133
Practice Address - Street 1:5992 BERRYHILL ROAD
Practice Address - Street 2:203
Practice Address - City:MILTON
Practice Address - State:FL
Practice Address - Zip Code:32570
Practice Address - Country:US
Practice Address - Phone:850-626-2131
Practice Address - Fax:850-626-2133
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-27
Last Update Date:2008-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL277632400Medicaid
FL277632400Medicaid