1265099386 NPI number — GULF COAST PAIN CONSULTANTS LLC

Table of content: (NPI 1265099386)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1265099386 NPI number — GULF COAST PAIN CONSULTANTS LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GULF COAST PAIN CONSULTANTS LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
CLEARWAY PAIN SOLUTIONS INSTITUTE
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1265099386
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/31/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
201 DEFENSE HWY STE 205
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ANNAPOLIS
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
21401-7096
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
855-527-7246
Provider Business Mailing Address Fax Number:
833-810-1165

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10437 SORRENTO RD STE 203
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PENSACOLA
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32507-7620
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
850-484-4080
Provider Business Practice Location Address Fax Number:
850-484-8801
Provider Enumeration Date:
05/23/2019

Additional Information

Authorized Official

Authorized Official Last Name:
MONTGOMERY
Authorized Official First Name:
KACEY
Authorized Official Middle Name:
A
Authorized Official Title or Position:
MEDICAL DIRECTOR
Authorized Official Telephone Number:
850-791-6895

Provider Taxonomy Codes

  • Taxonomy code: 207LP2900X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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