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General NPI Number Information
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NPI Number | 1093780959
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Entity Type | Organization
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Legal Business Name | GULF COAST PLASTIC SURGERY
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Dates
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Enumeration Date | 02/22/2006
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Last Update Date | 10/30/2009
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Provider Practice Location Address
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Address Line | 1133 45TH AVE
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City | GULFPORT
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State | MS
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Zip | 39501-2564
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Country | US
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Telephone | 228-865-7299
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 366
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City | GULFPORT
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State | MS
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Zip | 39502-0366
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Country | US
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Telephone | 228-865-7299
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Fax |
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Authorized Official
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Title or Position | OWNER MD
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Name | DR. ERIC J WYBLE
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Credential |
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Telephone | 228-865-7299
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208200000X
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Taxonomy Name | Plastic Surgery Physician
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License Number | 12046
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License Number State | MS
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