1285679050 NPI number — GULF COAST MEDICAL CENTER PRIMARY CARE LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1285679050 NPI number — GULF COAST MEDICAL CENTER PRIMARY CARE LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GULF COAST MEDICAL CENTER PRIMARY CARE 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:
Provider Other Organization Name Type Code:
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:
1285679050
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/24/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2202 STATE AVE
Provider Second Line Business Mailing Address:
STE. 207
Provider Business Mailing Address City Name:
PANAMA CITY
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32405-7601
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
850-784-2645
Provider Business Mailing Address Fax Number:
850-784-2646

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2202 STATE AVE
Provider Second Line Business Practice Location Address:
STE. 207
Provider Business Practice Location Address City Name:
PANAMA CITY
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32405-7601
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
850-784-2645
Provider Business Practice Location Address Fax Number:
850-784-2646
Provider Enumeration Date:
06/17/2006

Additional Information

Authorized Official

Authorized Official Last Name:
PICKLER
Authorized Official First Name:
MICKEY
Authorized Official Middle Name:
Authorized Official Title or Position:
VP
Authorized Official Telephone Number:
850-229-8288

Provider Taxonomy Codes

  • Taxonomy code: 207V00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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