Basic Information
| Provider Information | |||||||||
| NPI: | 1437114378 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | EMERALD COAST SURGERY CENTER, LP | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | EMERALD COAST SURGERY CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 995 MAR WALT DRIVE | ||||||||
| Address2: | |||||||||
| City: | FORT WALTON BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 32547 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8508637887 | ||||||||
| FaxNumber: | 8508636645 | ||||||||
| Practice Location | |||||||||
| Address1: | 995 MAR WALT DRIVE | ||||||||
| Address2: | |||||||||
| City: | FORT WALTON BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 32547 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8508637887 | ||||||||
| FaxNumber: | 8508636645 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/20/2006 | ||||||||
| LastUpdateDate: | 01/27/2015 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | KACHELHOFFER | ||||||||
| AuthorizedOfficialFirstName: | ANNE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 8508638165 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QA1903X | N | Ambulatory Health Care Facilities | Clinic/Center | Ambulatory Surgical | 261QA1903X | 996 | FL | Y | Ambulatory Health Care Facilities | Clinic/Center | Ambulatory Surgical |
ID Information
| ID | Type | State | Issuer | Description | 0791423 | 05 | FL | MEDICAID |