Healthcare Provider Details

I. General information

NPI: 1093780959
Provider Name (Legal Business Name): GULF COAST PLASTIC SURGERY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/22/2006
Last Update Date: 10/30/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1133 45TH AVE
GULFPORT MS
39501-2564
US

IV. Provider business mailing address

PO BOX 366
GULFPORT MS
39502-0366
US

V. Phone/Fax

Practice location:
  • Phone: 228-865-7299
  • Fax:
Mailing address:
  • Phone: 228-865-7299
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License Number12046
License Number StateMS

VIII. Authorized Official

Name: DR. ERIC J WYBLE
Title or Position: OWNER MD
Credential:
Phone: 228-865-7299