Basic Information
| Provider Information | |||||||||
| NPI: | 1851680789 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | GULFVIEW MEDICAL INSTITUTE PLLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | PREMIER MEDICAL INSTITUTE PL | ||||||||
| OtherOrganizationType: | 4 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 21942 EDGEWATER DR STE 1211 | ||||||||
| Address2: | |||||||||
| City: | PORT CHARLOTTE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 339529723 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9415052100 | ||||||||
| FaxNumber: | 9415056100 | ||||||||
| Practice Location | |||||||||
| Address1: | 21942 EDGEWATER DR | ||||||||
| Address2: | |||||||||
| City: | PORT CHARLOTTE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 339529723 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9415052100 | ||||||||
| FaxNumber: | 9415056100 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/31/2011 | ||||||||
| LastUpdateDate: | 06/30/2020 | ||||||||
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| AuthorizedOfficialLastName: | RAVID | ||||||||
| AuthorizedOfficialFirstName: | JOSEPH | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 9415052100 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 06/30/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | ME 106244 | FL | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 003XX | 01 | FL | BC/BS | OTHER | FB001A | 01 | FL | MEDICARE | OTHER | DS5131 | 01 | FL | RAIL ROAD MEDICARE | OTHER |