=====================================================
General NPI Number Information
=====================================================
NPI Number | 1700312824
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GULF COAST MEDICAL DOCTORS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/10/2017
-----------------------------------------------------
Last Update Date | 05/10/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 109 W 23RD ST SUITE N5
-----------------------------------------------------
City | PANAMA CITY
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32405-7610
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 850-769-1566
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 15834
-----------------------------------------------------
City | PANAMA CITY
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32406-5834
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 850-769-1566
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. AYMAN ABOULELA
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 850-769-1566
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 405300000X
-----------------------------------------------------
Taxonomy Name | Prevention Professional
-----------------------------------------------------
License Number | ME90177
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------