Basic Information
| Provider Information | |||||||||
| NPI: | 1508437351 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | GULF COAST HMA PHYSICIAN MANAGEMENT LLC | ||||||||
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| OtherOrganizationName: | GULF COAST HMA PHYSICIAN MANAGEMENT LLC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 689022 | ||||||||
| Address2: | |||||||||
| City: | FRANKLIN | ||||||||
| State: | TN | ||||||||
| PostalCode: | 370689022 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6154657211 | ||||||||
| FaxNumber: | 6156286877 | ||||||||
| Practice Location | |||||||||
| Address1: | 1700 E VENICE AVE | ||||||||
| Address2: | |||||||||
| City: | VENICE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 342923190 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9414837651 | ||||||||
| FaxNumber: | 9414837699 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/02/2021 | ||||||||
| LastUpdateDate: | 03/15/2022 | ||||||||
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| AuthorizedOfficialLastName: | JACKSON | ||||||||
| AuthorizedOfficialFirstName: | JENNIFER | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | SR DIR PROV ENROLLMENT & ONBOARDING | ||||||||
| AuthorizedOfficialTelephone: | 6154653334 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 03/15/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 207RE0101X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Endocrinology, Diabetes & Metabolism | 207RG0100X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology | 225X00000X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | 207VG0400X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Gynecology | 207X00000X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | 208G00000X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Thoracic Surgery (Cardiothoracic Vascular Surgery) | 225100000X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 363LF0000X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363A00000X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363AS0400X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical | 363L00000X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 207R00000X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 277033406 | 05 | FL | MEDICAID |