1124576079 NPI number — G MED II LLC

Table of content: (NPI 1124576079)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1124576079 NPI number — G MED II LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
G MED II 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:
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:
1124576079
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/06/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
20117 BOX CV
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAUCIER
Provider Business Mailing Address State Name:
MS
Provider Business Mailing Address Postal Code:
39574-8702
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
228-234-6236
Provider Business Mailing Address Fax Number:
228-265-5197

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4723 TENNESSEE AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GULFPORT
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
39501-8130
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
228-265-5193
Provider Business Practice Location Address Fax Number:
228-265-5197
Provider Enumeration Date:
09/20/2016

Additional Information

Authorized Official

Authorized Official Last Name:
GALLOTTE
Authorized Official First Name:
KATHERINE
Authorized Official Middle Name:
SUMMER
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
228-265-5193

Provider Taxonomy Codes

  • Taxonomy code: 333600000X , with the licence number:  14259/1.1 , registered in the state of MS ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336C0003X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 2164275 . This is a "PK" identifier . This identifiers is of the category "OTHER".




Copyright © 2007-2025 www.npivalidator.com