Healthcare Provider Details

I. General information

NPI: 1750614301
Provider Name (Legal Business Name): GULF COAST DERMATOLOGY & SKIN CARE CENTRE PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/15/2009
Last Update Date: 11/17/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

580 PROVIDENCE PARK DR E SECOND FLOOR
MOBILE AL
36695-4614
US

IV. Provider business mailing address

580 PROVIDENCE PARK DR E 2ND FLOOR
MOBILE AL
36695-4614
US

V. Phone/Fax

Practice location:
  • Phone: 251-631-3570
  • Fax: 251-631-3572
Mailing address:
  • Phone: 251-631-3570
  • Fax: 251-631-3572

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number21520
License Number StateAL

VIII. Authorized Official

Name: DR. THOMAS W BENDER III
Title or Position: M.D.
Credential: M.D.
Phone: 251-631-3570