Basic Information
| Provider Information | |||||||||
| NPI: | 1669712287 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | GULF COAST PAIN CONSULTANTS LLC | ||||||||
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| OtherOrganizationName: | CLEARWAY PAIN SOLUTIONS INSTITUTE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 201 DEFENSE HWY STE 205 | ||||||||
| Address2: | |||||||||
| City: | ANNAPOLIS | ||||||||
| State: | MD | ||||||||
| PostalCode: | 214017096 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8555277246 | ||||||||
| FaxNumber: | 8338101165 | ||||||||
| Practice Location | |||||||||
| Address1: | 4901 MARKET PLACE RD | ||||||||
| Address2: | |||||||||
| City: | PENSACOLA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 325048986 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8555277246 | ||||||||
| FaxNumber: | 8338101165 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/19/2013 | ||||||||
| LastUpdateDate: | 05/17/2022 | ||||||||
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| AuthorizedOfficialLastName: | MONTGOMERY | ||||||||
| AuthorizedOfficialFirstName: | KACEY | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | REGIONAL MEDICAL DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 8507916895 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
| NPICertificationDate: | 05/17/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208VP0014X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pain Medicine | Interventional Pain Medicine |
No ID Information.