Healthcare Provider Details

I. General information

NPI: 1023475985
Provider Name (Legal Business Name): GULF COAST SURGICAL GROUP, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/24/2016
Last Update Date: 09/09/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2439 COUNTRY PLACE BLVD SUITE 102
TRINITY FL
34655-1163
US

IV. Provider business mailing address

2439 COUNTRY PLACE BLVD SUITE 102
TRINITY FL
34655-1163
US

V. Phone/Fax

Practice location:
  • Phone: 727-845-1662
  • Fax: 727-264-8869
Mailing address:
  • Phone: 727-845-1662
  • Fax: 727-264-8869

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code208C00000X
TaxonomyColon & Rectal Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. JARED CONTE FRATTINI
Title or Position: CEO
Credential: MD
Phone: 727-845-1662