Provider Demographics
NPI:1386916237
Name:EMERALD COAST NECK & BACK CLINIC, P.A.
Entity type:Organization
Organization Name:EMERALD COAST NECK & BACK CLINIC, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTO
Authorized Official - Middle Name:W
Authorized Official - Last Name:KOULISIS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:850-279-6485
Mailing Address - Street 1:1003 COLLEGE BLVD W
Mailing Address - Street 2:SUITE 4
Mailing Address - City:NICEVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32578-1068
Mailing Address - Country:US
Mailing Address - Phone:850-279-6485
Mailing Address - Fax:850-279-6546
Practice Address - Street 1:1003 COLLEGE BLVD W
Practice Address - Street 2:SUITE 4
Practice Address - City:NICEVILLE
Practice Address - State:FL
Practice Address - Zip Code:32578-1068
Practice Address - Country:US
Practice Address - Phone:850-279-6485
Practice Address - Fax:850-279-6546
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-07
Last Update Date:2022-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0053933207X00000X, 207XS0117X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207XS0117XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryOrthopaedic Surgery of the SpineGroup - Single Specialty
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL162510700OtherDEPARTMENT OF LABOR
FL07915OtherBLUE CROSS BLUE SHIELD
FL256355000Medicaid
FL07915OtherBLUE CROSS BLUE SHIELD