Healthcare Provider Details

I. General information

NPI: 1194011288
Provider Name (Legal Business Name): GULF COAST PEDIATRICS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/27/2011
Last Update Date: 01/31/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5675 THREE NOTCH RD STE C
MOBILE AL
36619-1617
US

IV. Provider business mailing address

PO BOX 191178
MOBILE AL
36619-6178
US

V. Phone/Fax

Practice location:
  • Phone: 251-445-4440
  • Fax: 251-445-4435
Mailing address:
  • Phone: 251-445-4440
  • Fax: 251-445-4435

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number25929
License Number StateAL

VIII. Authorized Official

Name: MICHELLE K NAMAN
Title or Position: MANAGING PARTNER
Credential: MD
Phone: 251-445-4440