Healthcare Provider Details

I. General information

NPI: 1164379632
Provider Name (Legal Business Name): GULF COAST VASCULAR LABS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/13/2026
Last Update Date: 03/13/2026
Certification Date: 03/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1551 OLD SHELL RD
MOBILE AL
36604-1354
US

IV. Provider business mailing address

200 N WARNER RD STE 205
KING OF PRUSSIA PA
19406-2841
US

V. Phone/Fax

Practice location:
  • Phone: 251-433-1180
  • Fax:
Mailing address:
  • Phone: 610-644-8900
  • Fax: 484-924-0053

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: GREGG MILLER
Title or Position: AUTHORIZED OFFICIAL
Credential: MD
Phone: 717-515-4048