Healthcare Provider Details

I. General information

NPI: 1255625067
Provider Name (Legal Business Name): GULF COAST HMA PHYSICIAN MANAGEMENT LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/09/2011
Last Update Date: 11/27/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

417 COMMERCIAL CT SUITE A6
VENICE FL
34292-1655
US

IV. Provider business mailing address

5811 PELICAN BAY BLVD SUITE 500
NAPLES FL
34108-2733
US

V. Phone/Fax

Practice location:
  • Phone: 941-488-0074
  • Fax: 941-488-2074
Mailing address:
  • Phone: 239-598-3131
  • Fax: 239-592-0438

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208VP0000X
TaxonomyPain Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. MICHAEL L GINGRAS
Title or Position: VICE PRESIDENT
Credential:
Phone: 239-598-3131