Basic Information
| Provider Information | |||||||||
| NPI: | 1932470648 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | GULF COAST HMA PHYSICIAN MANAGEMENT LLC | ||||||||
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| OtherOrganizationName: | GULF COAST FOOT AND ANKLE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 689022 | ||||||||
| Address2: | |||||||||
| City: | FRANKLIN | ||||||||
| State: | TN | ||||||||
| PostalCode: | 370689022 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 1211 JACARANDA BLVD | ||||||||
| Address2: | |||||||||
| City: | VENICE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 342924520 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8443669362 | ||||||||
| FaxNumber: | 9414843748 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/26/2012 | ||||||||
| LastUpdateDate: | 10/23/2018 | ||||||||
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| AuthorizedOfficialLastName: | WRIGHT | ||||||||
| AuthorizedOfficialFirstName: | JAMES | ||||||||
| AuthorizedOfficialMiddleName: | P | ||||||||
| AuthorizedOfficialTitleorPosition: | VP, PHYSICIAN BUSINESS SERVICES | ||||||||
| AuthorizedOfficialTelephone: | 6157781502 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 213E00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Podiatric Medicine & Surgery Service Providers | Podiatrist |
No ID Information.