MEDICARE: GULFPORT SURGERY CENTER, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QA1903X	Ambulatory Surgical Clinic/Center	017	MS

General Provider Information

NPI Number	:	1326045444
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GULFPORT SURGERY CENTER, LLC

Provider Business Mailing Address
First Line	:	1300 BROAD AVE
Second Line	:
City	:	GULFPORT
State	:	MS
Zip	:	39501-2404
Country	:	US
Telephone Number	:	228-575-2200
Fax Number	:

Provider Business Practice Location Address
First Line	:	1300 BROAD AVE
Second Line	:
City	:	GULFPORT
State	:	MS
Zip	:	39501-2404
Country	:	US
Telephone Number	:	228-575-2200
Fax Number	:

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	WILLIAM BRIAN HERTZOG
Credential	:
Telephone Number	:	228-575-2220

Provider Enumeration Date	:	07/05/2005
Last Update Date	:	08/22/2020

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