=====================================================
General NPI Number Information
=====================================================
NPI Number | 1700137205
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GULF COAST INTERVENTIONAL PAIN MANAGEMENT CLINIC, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/24/2012
-----------------------------------------------------
Last Update Date | 05/11/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 15164 DEDEAUX RD STE B
-----------------------------------------------------
City | GULFPORT
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39503-3124
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 228-284-1642
-----------------------------------------------------
Fax | 228-284-1643
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 15164 DEDEAUX RD STE B
-----------------------------------------------------
City | GULFPORT
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39503-3124
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 228-284-1642
-----------------------------------------------------
Fax | 228-284-1643
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PHYSICIAN
-----------------------------------------------------
Name | SHAWN X. MEI
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 228-284-1642
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207LP2900X
-----------------------------------------------------
Taxonomy Name | Pain Medicine (Anesthesiology) Physician
-----------------------------------------------------
License Number | 18456
-----------------------------------------------------
License Number State | MS
-----------------------------------------------------