Healthcare Provider Details

I. General information

NPI: 1205983731
Provider Name (Legal Business Name): GULF SHORES FAMILY MEDICINE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/05/2007
Last Update Date: 04/02/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

204 W 19TH AVE
GULF SHORES AL
36542
US

IV. Provider business mailing address

P.O. BOX 1157
GULF SHORES AL
36547
US

V. Phone/Fax

Practice location:
  • Phone: 251-968-1810
  • Fax: 251-968-1817
Mailing address:
  • Phone: 251-968-1810
  • Fax: 251-968-1817

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number23373
License Number StateAL

VIII. Authorized Official

Name: DR. MARIROSE C. OLSON
Title or Position: PRESIDENT
Credential: M.D.
Phone: 251-968-1810