Basic Information
Provider Information | |||||||||
NPI: | 1104498286 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | GULF COAST HMA PHYSICIAN MANAGEMENT LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | GULF COAST HMA PHYSICIAN MANAGEMENT LLC | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 689022 | ||||||||
Address2: |   | ||||||||
City: | FRANKLIN | ||||||||
State: | TN | ||||||||
PostalCode: | 370689022 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6154657211 | ||||||||
FaxNumber: | 6156286877 | ||||||||
Practice Location | |||||||||
Address1: | 600 NOKOMIS AVE S STE 204 | ||||||||
Address2: |   | ||||||||
City: | VENICE | ||||||||
State: | FL | ||||||||
PostalCode: | 342853209 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9414837651 | ||||||||
FaxNumber: | 9414837699 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/16/2021 | ||||||||
LastUpdateDate: | 03/14/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | JACKSON | ||||||||
AuthorizedOfficialFirstName: | JENNIFER | ||||||||
AuthorizedOfficialMiddleName: | L | ||||||||
AuthorizedOfficialTitleorPosition: | SR DIR PROV ENROLLMENT & ONBOARDING | ||||||||
AuthorizedOfficialTelephone: | 6154653334 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 03/14/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 204F00000X |   |   | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Transplant Surgery |   | 207RG0100X |   |   | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology | 2084N0400X |   |   | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology |
ID Information
ID | Type | State | Issuer | Description | 277033422 | 05 | FL |   | MEDICAID |