1922100452 NPI number — FAMILY MEDICINE ASSOCIATES OF THE GULF COAST PLLC

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 1922100452 NPI number — FAMILY MEDICINE ASSOCIATES OF THE GULF COAST PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FAMILY MEDICINE ASSOCIATES OF THE GULF COAST PLLC
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:
6
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:
1922100452
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/21/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 6479
Provider Second Line Business Mailing Address:
8990 ORTEGA PARK DR
Provider Business Mailing Address City Name:
NAVARRE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32566-2079
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
850-936-8343
Provider Business Mailing Address Fax Number:
850-936-5338

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8990 ORTEGA PARK DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NAVARRE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32566-4141
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
850-936-8343
Provider Business Practice Location Address Fax Number:
850-936-5338
Provider Enumeration Date:
09/04/2006

Additional Information

Authorized Official

Authorized Official Last Name:
SVENDSEN
Authorized Official First Name:
PAMELA
Authorized Official Middle Name:
JILL
Authorized Official Title or Position:
PROPIERTOR
Authorized Official Telephone Number:
850-936-8343

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  94822 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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