Basic Information
| Provider Information | |||||||||
| NPI: | 1205805710 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | GULFCOAST PAIN & REHABILITATION, P.A. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 18838 S MEMORIAL DR | ||||||||
| Address2: | SUITE 102 | ||||||||
| City: | HUMBLE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 773384279 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2812529993 | ||||||||
| FaxNumber: | 2812529997 | ||||||||
| Practice Location | |||||||||
| Address1: | 18838 S MEMORIAL DR | ||||||||
| Address2: | SUITE 102 | ||||||||
| City: | HUMBLE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 773384279 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2812529993 | ||||||||
| FaxNumber: | 2812529997 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/16/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | KORIVI | ||||||||
| AuthorizedOfficialFirstName: | NAVEENDRA | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 2812529993 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | D.O. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208100000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation |
No ID Information.