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General NPI Number Information
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NPI Number | 1104904077
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Entity Type | Organization
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Legal Business Name | GULF COAST GASTROENTEROLOGY, PA
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Dates
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Enumeration Date | 11/01/2006
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Last Update Date | 09/18/2023
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Provider Practice Location Address
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Address Line | 219 OAK DR S STE A
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City | LAKE JACKSON
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State | TX
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Zip | 77566-5675
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Country | US
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Telephone | 979-297-4033
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Fax | 979-297-4099
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Provider Business Mailing Address
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Address Line | 104 CIRCLE WAY ST STE B
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City | LAKE JACKSON
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State | TX
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Zip | 77566-5200
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Country | US
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Telephone | 979-297-4033
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Fax |
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Authorized Official
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Title or Position | OFFICE MANAGER
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Name | MRS. BRITIANY BUSH
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Credential |
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Telephone | 979-297-4033
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207RG0100X
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Taxonomy Name | Gastroenterology Physician
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License Number |
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License Number State |
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