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General NPI Number Information
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NPI Number | 1740291145
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Entity Type | Organization
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Legal Business Name | GULFPORT SURGERY CLINIC
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Dates
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Enumeration Date | 08/10/2006
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Last Update Date | 06/11/2020
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Provider Practice Location Address
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Address Line | 1312 44TH AVE
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City | GULFPORT
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State | MS
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Zip | 39501-2552
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Country | US
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Telephone | 228-822-6160
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Fax | 228-539-8327
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Provider Business Mailing Address
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Address Line | 1312 44TH AVE
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City | GULFPORT
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State | MS
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Zip | 39501-2552
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Country | US
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Telephone | 228-822-6160
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Fax | 228-539-8327
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Authorized Official
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Title or Position | OWNER
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Name | DR. THOMAS PAUL MACE
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Credential | M.D.
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Telephone | 228-822-6160
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number | 13995
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License Number State | MS
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