Basic Information
| Provider Information | |||||||||
| NPI: | 1770881112 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | GULF COAST HMA PHYSICIAN MANAGEMENT LLC | ||||||||
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| OtherOrganizationName: | GCMG-DIAGNOSIC CENTER/LAB | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5811 PELICAN BAY BLVD | ||||||||
| Address2: | SUITE 500 | ||||||||
| City: | NAPLES | ||||||||
| State: | FL | ||||||||
| PostalCode: | 341082733 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2395983131 | ||||||||
| FaxNumber: | 2395920438 | ||||||||
| Practice Location | |||||||||
| Address1: | 1700 E VENICE AVE | ||||||||
| Address2: | |||||||||
| City: | VENICE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 342923190 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2395983131 | ||||||||
| FaxNumber: | 2395920438 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/09/2011 | ||||||||
| LastUpdateDate: | 11/27/2012 | ||||||||
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| AuthorizedOfficialLastName: | GINGRAS | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | VICE PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 2395983131 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | HEALTH MANAGEMENT ASSOCIATES, INC. | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 291U00000X | Y | Laboratories | Clinical Medical Laboratory |
No ID Information.