1376532788 NPI number — GULF COAST DERMATOLOGY, PA

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 1376532788 NPI number — GULF COAST DERMATOLOGY, PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GULF COAST DERMATOLOGY, PA
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:
1376532788
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/20/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1304 44TH AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GULFPORT
Provider Business Mailing Address State Name:
MS
Provider Business Mailing Address Postal Code:
39501-2552
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
228-868-4006
Provider Business Mailing Address Fax Number:
228-868-9545

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1304 44TH 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:
39501-2552
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
228-868-4006
Provider Business Practice Location Address Fax Number:
228-868-9545
Provider Enumeration Date:
10/18/2005

Additional Information

Authorized Official

Authorized Official Last Name:
CRANE
Authorized Official First Name:
GWENDOLYN
Authorized Official Middle Name:
A
Authorized Official Title or Position:
PHYSICIAN
Authorized Official Telephone Number:
228-868-4006

Provider Taxonomy Codes

  • Taxonomy code: 207N00000X , with the licence number:  14316 , registered in the state of MS ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 04922734 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".
  • Identifier: 070007893 . This is a "MEDICARE RR" identifier , issued by the state of ( MS ) . This identifiers is of the category "OTHER".




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