Basic Information
| Provider Information | |||||||||
| NPI: | 1063755239 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | GULF COAST RADIATION AND RADIOSURGERY, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 29653 ANCHOR CROSS BLVD | ||||||||
| Address2: | |||||||||
| City: | DAPHNE | ||||||||
| State: | AL | ||||||||
| PostalCode: | 365269594 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2516261712 | ||||||||
| FaxNumber: | 2516269355 | ||||||||
| Practice Location | |||||||||
| Address1: | 5151 N 9TH AVE | ||||||||
| Address2: | |||||||||
| City: | PENSACOLA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 325048721 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2516261755 | ||||||||
| FaxNumber: | 2516269355 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/05/2013 | ||||||||
| LastUpdateDate: | 04/09/2013 | ||||||||
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| AuthorizedOfficialLastName: | SAWRIE | ||||||||
| AuthorizedOfficialFirstName: | STEPHEN | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 2516261712 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0001X | ME108535 | FL | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Radiation Oncology |
No ID Information.