Provider Demographics
NPI:1154773950
Name:EMERALD COAST INFECTIOUS DISEASES MEDICAL GROUP, PA
Entity type:Organization
Organization Name:EMERALD COAST INFECTIOUS DISEASES MEDICAL GROUP, PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT OF OPERATIONS
Authorized Official - Prefix:MR
Authorized Official - First Name:ERIC
Authorized Official - Middle Name:
Authorized Official - Last Name:SQUATRITO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:724-977-8498
Mailing Address - Street 1:1620 W. NORTHWEST HWY
Mailing Address - Street 2:SUITE 100
Mailing Address - City:GRAPEVINE
Mailing Address - State:TX
Mailing Address - Zip Code:76051
Mailing Address - Country:US
Mailing Address - Phone:817-572-0009
Mailing Address - Fax:817-572-0221
Practice Address - Street 1:917 MAR WALT DRIVE
Practice Address - Street 2:SUITE D
Practice Address - City:FORT WALTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:32547
Practice Address - Country:US
Practice Address - Phone:850-312-3570
Practice Address - Fax:850-312-3090
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:EMERALD COAST INFECTIOUS DISEASES
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-07-06
Last Update Date:2025-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPH30219333600000X
3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1165528300Medicaid
2160919OtherPK