Healthcare Provider Details

I. General information

NPI: 1477327385
Provider Name (Legal Business Name): GULF COAST PATHOLOGY PROGRAM PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/10/2023
Last Update Date: 11/10/2023
Certification Date: 11/10/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12141 RICHMOND AVE
HOUSTON TX
77082-2408
US

IV. Provider business mailing address

PO BOX 746559
ATLANTA GA
30374-6559
US

V. Phone/Fax

Practice location:
  • Phone: 281-588-8013
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License Number
License Number State

VIII. Authorized Official

Name: MICHAEL JAMAINE DAVIS
Title or Position: CHIEF OF FINANCIAL OFFICER
Credential:
Phone: 561-402-4256