Basic Information
| Provider Information | |||||||||
| NPI: | 1578733614 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | GULF COAST COMPREHENSIVE CARE LLP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 190 W DEARBORN ST | ||||||||
| Address2: | |||||||||
| City: | ENGLEWOOD | ||||||||
| State: | FL | ||||||||
| PostalCode: | 342233237 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9414732913 | ||||||||
| FaxNumber: | 9414739813 | ||||||||
| Practice Location | |||||||||
| Address1: | 190 W DEARBORN ST | ||||||||
| Address2: | |||||||||
| City: | ENGLEWOOD | ||||||||
| State: | FL | ||||||||
| PostalCode: | 342233237 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9414732913 | ||||||||
| FaxNumber: | 9414739813 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/05/2008 | ||||||||
| LastUpdateDate: | 03/05/2008 | ||||||||
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| AuthorizedOfficialLastName: | CHACE | ||||||||
| AuthorizedOfficialFirstName: | TODD | ||||||||
| AuthorizedOfficialMiddleName: | R | ||||||||
| AuthorizedOfficialTitleorPosition: | VICE PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 9414732913 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | DO | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | OS5249 | FL | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 207RG0100X | ME61249 | FL | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology | 207R00000X | ME48779 | FL | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.