| Entity Name: | EMERALD COAST EMERGENCY PHYSICIANS, PLLC |
| Jurisdiction: | FLORIDA |
| Filing Type: | Florida Limited Liability Company |
| Status: | Active |
| Date Filed: | 26 Sep 2023 (a year ago) |
| Document Number: | L23000446716 |
| FEI/EIN Number | 93-3788516 |
| Address: | 71 WINDROW WAY, INLET BEACH, FL 32461 |
| Mail Address: | 71 WINDROW WAY, INLET BEACH, FL 32461 |
| ZIP code: | 32461 |
| County: | Walton |
| Place of Formation: | FLORIDA |
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1396980926 | 2008-12-11 | 2009-09-21 | PO BOX 602162, CHARLOTTE, NC, 282602162, US | 996 AIRPORT RD, DESTIN, FL, 325412824, US | |||||||||||||||||||||||||||||
|
|||||||||||||||||||||||||||||||||
| Phone | +1 866-916-5259 |
| Fax | 2319224030 |
| Phone | +1 850-837-9194 |
Authorized person
| Name | DR. DERIK K KING |
| Role | LLP MANAGING PARTNER |
| Phone | 8669165259 |
Taxonomy
| Taxonomy Code | 207P00000X - Emergency Medicine Physician |
| Is Primary | Yes |
Other Provider Identifiers
| Issuer | BLUE SHIELD |
| Number | 72205 |
| State | FL |
| Issuer | MEDICAID |
| Number | 000625802 |
| State | FL |
| Name | Role | Address |
|---|---|---|
| JACKSON, ROBERT C, ESQ. | Agent | 304 MAGNOLIA AVENUE, PANAMA CITY, FL 32401 |
| Name | Role | Address |
|---|---|---|
| COSTELLO, TIMOTHY | Authorized Member | 71 WINDROW WAY, INLET BEACH, FL 32461 |
| SMILEY, JUSTIN | Authorized Member | 177 TROPICAL BREEZE DR, SANTA ROSA BEACH, FL 32459 |
| REYES, JOSE | Authorized Member | 71 KOKOMO ROW, DESTIN, FL 32541 |
| JONES, JONATHAN | Authorized Member | 6428 WEST HWY 98, BOX 924, PORT SAINT JOE, FL 32456 |
| LANDA, MARTIN | Authorized Member | 2936 PINE VALLEY DR, MIRAMAR BEACH, FL 32550 |
| Name | Date |
|---|---|
| ANNUAL REPORT | 2024-02-16 |
| Florida Limited Liability | 2023-09-26 |
Date of last update: 08 Jan 2025
Sources: Florida Department of State
