Basic Information
| Provider Information | |||||||||
| NPI: | 1720277445 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | GULF COAST PSYCHIATRIC CARE | ||||||||
| LastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 421 DELMAS AVE | ||||||||
| Address2: | |||||||||
| City: | PASCAGOULA | ||||||||
| State: | MS | ||||||||
| PostalCode: | 395674136 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2286969224 | ||||||||
| FaxNumber: | 2286969228 | ||||||||
| Practice Location | |||||||||
| Address1: | 421 DELMAS AVE | ||||||||
| Address2: | |||||||||
| City: | PASCAGOULA | ||||||||
| State: | MS | ||||||||
| PostalCode: | 395674136 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2286969224 | ||||||||
| FaxNumber: | 2286969228 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/18/2007 | ||||||||
| LastUpdateDate: | 10/13/2008 | ||||||||
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| AuthorizedOfficialLastName: | COX | ||||||||
| AuthorizedOfficialFirstName: | SERA | ||||||||
| AuthorizedOfficialMiddleName: | K | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 2286969224 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | GULF COAST PSYCHIATRIC CARE | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | 19819 | MS | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | 01708228 | 05 | MS | MEDICAID | 427578364 | 01 | MS | BCBS | OTHER | 09734214 | 01 | MS | MEDICAID GROUP NUMBER | OTHER |