Basic Information
| Provider Information | |||||||||
| NPI: | 1043825540 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | GULF COAST VASCULAR CARE, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3001 PALM HARBOR BLVD STE A | ||||||||
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| City: | PALM HARBOR | ||||||||
| State: | FL | ||||||||
| PostalCode: | 346831930 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7274740090 | ||||||||
| FaxNumber: | 7274740055 | ||||||||
| Practice Location | |||||||||
| Address1: | 14219 COOK RD | ||||||||
| Address2: | |||||||||
| City: | BILOXI | ||||||||
| State: | MS | ||||||||
| PostalCode: | 395329719 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2282070810 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/11/2020 | ||||||||
| LastUpdateDate: | 09/11/2020 | ||||||||
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| AuthorizedOfficialLastName: | GARDNER | ||||||||
| AuthorizedOfficialFirstName: | KEVIN | ||||||||
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| AuthorizedOfficialTitleorPosition: | OPERATIONS OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 7274740090 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 09/11/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0204X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Vascular & Interventional Radiology | 207RN0300X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Nephrology |
No ID Information.