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General NPI Number Information
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NPI Number | 1477530657
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Entity Type | Organization
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Legal Business Name | GULFPORT OBSTETRICAL & GYNECOLOGICAL CLINIC, PA
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Dates
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Enumeration Date | 12/28/2005
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 4502 OLD PASS RD
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City | GULFPORT
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State | MS
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Zip | 39501-2585
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Country | US
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Telephone | 228-863-9977
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Fax | 228-822-2174
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Provider Business Mailing Address
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Address Line | 4502 OLD PASS RD
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City | GULFPORT
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State | MS
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Zip | 39501-2585
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Country | US
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Telephone | 228-863-9977
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Fax | 228-822-2174
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Authorized Official
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Title or Position | ADMINISTRATOR
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Name | MR. DAVID P BURKART
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Credential |
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Telephone | 228-863-9977
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251B00000X
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Taxonomy Name | Case Management Agency
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License Number | 82612
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License Number State | MS
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