Healthcare Provider Details

I. General information

NPI: 1457534166
Provider Name (Legal Business Name): GORDON THAMES COUCH M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/17/2007
Last Update Date: 05/09/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4900 BAYOU BLVD SUITE 104
PENSACOLA FL
32503-2525
US

IV. Provider business mailing address

4900 BAYOU BLVD SUITE 104
PENSACOLA FL
32503-2525
US

V. Phone/Fax

Practice location:
  • Phone: 850-477-2330
  • Fax: 850-484-8733
Mailing address:
  • Phone: 850-477-2330
  • Fax: 850-484-8733

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207VG0400X
TaxonomyGynecology Physician
License NumberME0013562
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: