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General NPI Number Information
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NPI Number | 1417237785
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Entity Type | Organization
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Legal Business Name | GULF COAST MOBILE MEDICINE, LLC
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Dates
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Enumeration Date | 08/18/2011
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Last Update Date | 08/18/2011
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Provider Practice Location Address
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Address Line | 8655 IBIS COVE CIR
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City | NAPLES
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State | FL
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Zip | 34119-7728
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Country | US
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Telephone | 239-455-8047
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Fax | 239-455-8048
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Provider Business Mailing Address
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Address Line | 8655 IBIS COVE CIR
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City | NAPLES
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State | FL
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Zip | 34119-7728
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Country | US
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Telephone | 239-455-8047
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Fax | 239-455-8048
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Authorized Official
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Title or Position | MANAGING MEMBER
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Name | MR. MARC E. MCCOLLAUM
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Credential | PA-C
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Telephone | 239-455-8048
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363AM0700X
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Taxonomy Name | Medical Physician Assistant
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License Number | 9102277
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License Number State | FL
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