1295339638 NPI number — GULF SHORES EMERGENCY PHYSICIANS, 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 1295339638 NPI number — GULF SHORES EMERGENCY PHYSICIANS, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GULF SHORES EMERGENCY PHYSICIANS, 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:
1295339638
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/22/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5665 NEW NORTHSIDE DR STE 320
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ATLANTA
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30328-5834
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
770-874-5400
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3590 GULF SHORES PARKWAY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GULF SHORES
Provider Business Practice Location Address State Name:
AL
Provider Business Practice Location Address Postal Code:
36542
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
251-215-4853
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/25/2020

Additional Information

Authorized Official

Authorized Official Last Name:
LARSEN
Authorized Official First Name:
KIM
Authorized Official Middle Name:
Authorized Official Title or Position:
DIRECTOR OF CREDENTIALING
Authorized Official Telephone Number:
770-874-5400

Provider Taxonomy Codes

  • Taxonomy code: 207P00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 109743300 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com