Basic Information
| Provider Information | |||||||||
| NPI: | 1710049200 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | GULFSHORE MEDICAL CONSULTANTS, PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 22A DOCTORS DR | ||||||||
| Address2: | |||||||||
| City: | OCEAN SPRINGS | ||||||||
| State: | MS | ||||||||
| PostalCode: | 395645721 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2288721951 | ||||||||
| FaxNumber: | 2288759998 | ||||||||
| Practice Location | |||||||||
| Address1: | 22A DOCTORS DR | ||||||||
| Address2: | |||||||||
| City: | OCEAN SPRINGS | ||||||||
| State: | MS | ||||||||
| PostalCode: | 395645721 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2288721951 | ||||||||
| FaxNumber: | 2288759998 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/14/2006 | ||||||||
| LastUpdateDate: | 01/22/2008 | ||||||||
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| AuthorizedOfficialLastName: | RODBERG | ||||||||
| AuthorizedOfficialFirstName: | GARY | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 2288721951 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0200X | 18516 | MS | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Critical Care Medicine | 207RC0200X | 17943 | MS | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Critical Care Medicine | 207RP1001X | 14252 | MS | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Pulmonary Disease | 207RP1001X | 18516 | MS | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Pulmonary Disease | 207RP1001X | 17943 | MS | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Pulmonary Disease | 207RR0500X | 15014 | MS | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Rheumatology | 207RS0012X | 14252 | MS | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Sleep Medicine | 207RS0012X | 17943 | MS | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Sleep Medicine | 207RC0200X | 14252 | MS | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Critical Care Medicine |
ID Information
| ID | Type | State | Issuer | Description | 00114969 | 05 | MS | MEDICAID | 00126926 | 05 | MS | MEDICAID | 09015817 | 05 | MS | MEDICAID | 00117171 | 05 | MS | MEDICAID | 07521804 | 05 | MS | MEDICAID |