Healthcare Provider Details

I. General information

NPI: 1710049200
Provider Name (Legal Business Name): GULFSHORE MEDICAL CONSULTANTS, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/14/2006
Last Update Date: 01/22/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22A DOCTORS DR
OCEAN SPRINGS MS
39564-5721
US

IV. Provider business mailing address

22A DOCTORS DR
OCEAN SPRINGS MS
39564-5721
US

V. Phone/Fax

Practice location:
  • Phone: 228-872-1951
  • Fax: 228-875-9998
Mailing address:
  • Phone: 228-872-1951
  • Fax: 228-875-9998

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License Number18516
License Number StateMS
# 2
Primary TaxonomyN
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License Number17943
License Number StateMS
# 3
Primary TaxonomyN
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number14252
License Number StateMS
# 4
Primary TaxonomyN
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number18516
License Number StateMS
# 5
Primary TaxonomyN
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number17943
License Number StateMS
# 6
Primary TaxonomyN
Taxonomy Code207RR0500X
TaxonomyRheumatology Physician
License Number15014
License Number StateMS
# 7
Primary TaxonomyN
Taxonomy Code207RS0012X
TaxonomySleep Medicine (Internal Medicine) Physician
License Number14252
License Number StateMS
# 8
Primary TaxonomyN
Taxonomy Code207RS0012X
TaxonomySleep Medicine (Internal Medicine) Physician
License Number17943
License Number StateMS
# 9
Primary TaxonomyY
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License Number14252
License Number StateMS

VIII. Authorized Official

Name: GARY M RODBERG
Title or Position: PRESIDENT
Credential: MD
Phone: 228-872-1951