Healthcare Provider Details

I. General information

NPI: 1376887620
Provider Name (Legal Business Name): GULF COAST CHILDRENS CLINIC, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/26/2012
Last Update Date: 11/26/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

930 MAIN STREET SUITE A
WIGGNIS MS
39564-0000
US

IV. Provider business mailing address

3650 GROVELAND RD
OCEAN SPRINGS MS
39564-5754
US

V. Phone/Fax

Practice location:
  • Phone: 228-875-0780
  • Fax: 228-875-1009
Mailing address:
  • Phone: 228-875-0780
  • Fax: 228-875-1009

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: MEICHELLE HARVEY
Title or Position: ADMINISTRATOR
Credential:
Phone: 228-875-0780