Healthcare Provider Details

I. General information

NPI: 1992083562
Provider Name (Legal Business Name): GULF COAST ANESTHESIA GROUP PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/29/2011
Last Update Date: 07/29/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6002 BERRYHILL RD
MILTON FL
32570-5062
US

IV. Provider business mailing address

PO BOX 2297
ASHEVILLE NC
28802-2297
US

V. Phone/Fax

Practice location:
  • Phone: 850-626-7762
  • Fax:
Mailing address:
  • Phone: 828-210-9386
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number
License Number State

VIII. Authorized Official

Name: KENNETH R ELLINGTON
Title or Position: PRESIDENT
Credential: MD
Phone: 828-210-9386