=====================================================
General NPI Number Information
=====================================================
NPI Number | 1750822342
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GULF COAST HEALTH SYSTEM IMAGING, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/15/2017
-----------------------------------------------------
Last Update Date | 03/15/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 13137 SORRENTO RD
-----------------------------------------------------
City | PENSACOLA
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32507
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 615-974-1972
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1642 WESTGATE CIR STE 202
-----------------------------------------------------
City | BRENTWOOD
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37027-8195
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 615-974-1972
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | GENERAL COUNSEL
-----------------------------------------------------
Name | RYAN D BROWN
-----------------------------------------------------
Credential | JD
-----------------------------------------------------
Telephone | 615-974-1972
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM1200X
-----------------------------------------------------
Taxonomy Name | Magnetic Resonance Imaging (MRI) Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 261QR0206X
-----------------------------------------------------
Taxonomy Name | Mammography Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 261QR0200X
-----------------------------------------------------
Taxonomy Name | Radiology Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------