Healthcare Provider Details

I. General information

NPI: 1427271840
Provider Name (Legal Business Name): PRIMARY CARE MEDICAL CENTER OF GULFPORT, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/11/2007
Last Update Date: 07/13/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15444 DEDEAUX RD STE. B
GULFPORT MS
39503-2637
US

IV. Provider business mailing address

15444 DEDEAUX RD STE. B
GULFPORT MS
39503-2637
US

V. Phone/Fax

Practice location:
  • Phone: 228-832-9038
  • Fax: 228-832-9990
Mailing address:
  • Phone: 228-832-9038
  • Fax: 228-832-9990

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2083X0100X
TaxonomyOccupational Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: MRS. ANGELA V MCCLURE
Title or Position: INSURANCE CLERK
Credential:
Phone: 228-832-9038