Emerald Coast Neck & Back Clinic, P.a.

Primary specialty

Orthopaedic Surgery of the Spine PhysicianTaxonomy code 207XS0117X

License

ME0053933 Issued in FL

Legal business name

EMERALD COAST NECK & BACK CLINIC, P.A.

Practice address

1003 College Blvd W
Suite 4
Niceville, FL 32578-1068

Phone

(850) 279-6485

Fax

(850) 279-6546

NPI assigned

Feb 7, 2012

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Christo W. Koulisis, M.D.NPI 1780673749

Title

President

Phone

(850) 279-6485

Specialties & licenses 2

Addresses

Other identifiers 3

Medicare fee-for-service enrollment

Enrolled in FL

Enrollment records 1

Locations

Practitioners 2

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

• Christo W Koulisis, MD

  • Specialist
  • Niceville, FL
  • NPI 1780673749

  FL, Orthopaedic Surgery

  Medicare reassignment NPD Authorized official
• Alfred Cardet, MD

  • Specialist
  • Crestview, FL
  • NPI 1770572745
  NPD (past)

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1328572800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1672272000000",
    "number": "1386916237",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1003 COLLEGE BLVD W",
            "address_2": "SUITE 4",
            "city": "NICEVILLE",
            "state": "FL",
            "postal_code": "325781068",
            "telephone_number": "850-279-6485",
            "fax_number": "850-279-6546"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1003 COLLEGE BLVD W",
            "address_2": "SUITE 4",
            "city": "NICEVILLE",
            "state": "FL",
            "postal_code": "325781068",
            "telephone_number": "850-279-6485",
            "fax_number": "850-279-6546"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "EMERALD COAST NECK & BACK CLINIC, P.A.",
        "organizational_subpart": "NO",
        "enumeration_date": "2012-02-07",
        "last_updated": "2022-12-29",
        "certification_date": "2022-12-29",
        "status": "A",
        "authorized_official_last_name": "KOULISIS",
        "authorized_official_first_name": "CHRISTO",
        "authorized_official_middle_name": "W.",
        "authorized_official_title_or_position": "PRESIDENT",
        "authorized_official_telephone_number": "850-279-6485",
        "authorized_official_credential": "M.D."
    },
    "taxonomies": [
        {
            "code": "207X00000X",
            "taxonomy_group": "193400000X MULTIPLE SINGLE SPECIALTY GROUP",
            "desc": "Orthopaedic Surgery",
            "state": "FL",
            "license": "ME0053933",
            "primary": false
        },
        {
            "code": "207XS0117X",
            "taxonomy_group": "193400000X MULTIPLE SINGLE SPECIALTY GROUP",
            "desc": "Orthopaedic Surgery, Orthopaedic Surgery of the Spine",
            "state": "FL",
            "license": "ME0053933",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "DEPARTMENT OF LABOR",
            "identifier": "162510700",
            "state": "FL"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "BLUE CROSS BLUE SHIELD",
            "identifier": "07915",
            "state": "FL"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "256355000",
            "state": "FL"
        }
    ],
    "endpoints": [],
    "other_names": []
}

• Emerald Coast Children'S Advocacy Center Inc.
• Emerald Coast Chiropractic Inc
• Emerald Coast Emergency Physicians LLP
• Emerald Coast Health Institute, Inc.
• Emerald Coast Lifecare, Inc.
• Emerald Coast Periodontics
• Emerald Coast Periodontics, P.a.
• Emerald Coast Services
• Emerald Coast Speech Services LLC
• Emerald Coast Wellness Center, LLC

• All providers in Niceville, FL
• Orthopaedic Surgery of the Spine Physician in Florida

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Dec 29, 2022; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.