Basic Information
| Provider Information | |||||||||
| NPI: | 1689636458 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | EMERALD COAST PATHOLOGY ASSOCIATES PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 100559 | ||||||||
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| City: | FLORENCE | ||||||||
| State: | SC | ||||||||
| PostalCode: | 295010559 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8436644300 | ||||||||
| FaxNumber: | 8436644308 | ||||||||
| Practice Location | |||||||||
| Address1: | 1000 MAR WALT DR | ||||||||
| Address2: | |||||||||
| City: | FORT WALTON BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 325476708 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8508637660 | ||||||||
| FaxNumber: | 8503157808 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/05/2006 | ||||||||
| LastUpdateDate: | 03/17/2008 | ||||||||
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| AuthorizedOfficialLastName: | BLANCHARD | ||||||||
| AuthorizedOfficialFirstName: | ROBERT | ||||||||
| AuthorizedOfficialMiddleName: | NEIL | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 8508637660 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207ZP0102X | ME66117 | FL | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology |
ID Information
| ID | Type | State | Issuer | Description | 21346 | 01 | FL | BCBS | OTHER |