Healthcare Provider Details

I. General information

NPI: 1306587241
Provider Name (Legal Business Name): GULF COAST PAIN CONSULTANTS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/05/2022
Last Update Date: 02/15/2024
Certification Date: 02/15/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7552 NAVARRE PKWY UNIT 54
NAVARRE FL
32566-7305
US

IV. Provider business mailing address

201 DEFENSE HWY STE 205
ANNAPOLIS MD
21401-7096
US

V. Phone/Fax

Practice location:
  • Phone: 855-527-7246
  • Fax: 833-810-1165
Mailing address:
  • Phone: 855-527-7246
  • Fax: 866-229-5063

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2081P2900X
TaxonomyPain Medicine (Physical Medicine & Rehabilitation) Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code208VP0000X
TaxonomyPain Medicine Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State

VIII. Authorized Official

Name: KACEY A MONTGOMERY
Title or Position: REGIONAL MEDICAL DIRECTOR
Credential: M.D.
Phone: 352-359-6634