Basic Information
Provider Information | |||||||||
NPI: | 1841435476 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | EMERALD COAST EMERGENCY PHYSICIANS LLP | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 602162 | ||||||||
Address2: |   | ||||||||
City: | CHARLOTTE | ||||||||
State: | NC | ||||||||
PostalCode: | 282602162 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8669165259 | ||||||||
FaxNumber: | 2319224030 | ||||||||
Practice Location | |||||||||
Address1: | 2190 HIGHWAY 85 N | ||||||||
Address2: |   | ||||||||
City: | NICEVILLE | ||||||||
State: | FL | ||||||||
PostalCode: | 325781045 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8506784131 | ||||||||
FaxNumber: | 8507299473 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/11/2008 | ||||||||
LastUpdateDate: | 06/17/2009 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | KING | ||||||||
AuthorizedOfficialFirstName: | DERIK | ||||||||
AuthorizedOfficialMiddleName: | K | ||||||||
AuthorizedOfficialTitleorPosition: | LLP MANAGING PARTNER | ||||||||
AuthorizedOfficialTelephone: | 8669165259 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | DR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | MD | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X |   |   | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 000625800 | 05 | FL |   | MEDICAID | 72205 | 01 | FL | BLUE SHIELD | OTHER |