1265820823 NPI number — PATTON MEDICAL OF THE GULF COAST, INC

Table of content: (NPI 1265820823)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1265820823 NPI number — PATTON MEDICAL OF THE GULF COAST, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PATTON MEDICAL OF THE GULF COAST, INC
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:
1265820823
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/04/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3002 BIENVILLE BLVD
Provider Second Line Business Mailing Address:
SUITE C
Provider Business Mailing Address City Name:
OCEAN SPRINGS
Provider Business Mailing Address State Name:
MS
Provider Business Mailing Address Postal Code:
39564-4354
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
228-872-8685
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1805 OLD SHELL RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MOBILE
Provider Business Practice Location Address State Name:
AL
Provider Business Practice Location Address Postal Code:
36607-3416
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
251-459-8600
Provider Business Practice Location Address Fax Number:
228-872-8686
Provider Enumeration Date:
01/06/2015

Additional Information

Authorized Official

Authorized Official Last Name:
WADE
Authorized Official First Name:
WILLIAM
Authorized Official Middle Name:
KEITH
Authorized Official Title or Position:
OWNER VP
Authorized Official Telephone Number:
228-872-8685

Provider Taxonomy Codes

  • Taxonomy code: 335E00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1265820823 , issued by the state of ( AL ) . This identifiers is of the category "MEDICAID".




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