Healthcare Provider Details

I. General information

NPI: 1104278902
Provider Name (Legal Business Name): GULF COAST PAIN CONSULTANTS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/06/2016
Last Update Date: 01/31/2023
Certification Date: 01/31/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3810 HIGHWAY 90
PACE FL
32571-1014
US

IV. Provider business mailing address

201 DEFENSE HWY STE 205
ANNAPOLIS MD
21401-7096
US

V. Phone/Fax

Practice location:
  • Phone: 850-484-4080
  • Fax:
Mailing address:
  • Phone: 855-527-7246
  • Fax: 833-810-1165

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State

VIII. Authorized Official

Name: KACEY A MONTGOMERY
Title or Position: MEDICAL DIRECTOR
Credential: MD
Phone: 850-791-6895