Organization
EMERALD COAST SURGICAL SPECIALISTS PA
Active
Organization subpart
No
Provider details
NPI number
Authorized official
RANDALL L MCKISSACK MD (OWNER/PHYSICIAN)
(850) 626-2131
Entity
Organization
Contact information
Practice address
5992 BERRYHILL ROAD, 203, MILTON, FL 32570
(850) 626-2131
(850) 626-2133
Mailing address
PO BOX 30215, PENSACOLA, FL 32503-1215
(850) 626-2131
(850) 626-2133
Taxonomy
Speciality
Code
Description
License number
State
208600000X
Surgery Physician
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
277632400
—
FL
Enumeration date
12/27/2007
Last updated
05/30/2008
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