=====================================================
General NPI Number Information
=====================================================
NPI Number | 1043825540
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GULF COAST VASCULAR CARE, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/11/2020
-----------------------------------------------------
Last Update Date | 09/11/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 14219 COOK RD
-----------------------------------------------------
City | BILOXI
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39532-9719
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 228-207-0810
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3001 PALM HARBOR BLVD STE A
-----------------------------------------------------
City | PALM HARBOR
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34683-1930
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 727-474-0090
-----------------------------------------------------
Fax | 727-474-0055
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OPERATIONS OFFICER
-----------------------------------------------------
Name | KEVIN GARDNER
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 727-474-0090
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2085R0204X
-----------------------------------------------------
Taxonomy Name | Vascular & Interventional Radiology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207RN0300X
-----------------------------------------------------
Taxonomy Name | Nephrology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------