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General NPI Number Information
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NPI Number | 1952697724
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Entity Type | Organization
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Legal Business Name | GULFSIDE MEDICAL CARE LLC
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Dates
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Enumeration Date | 06/21/2011
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Last Update Date | 06/30/2011
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Provider Practice Location Address
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Address Line | 12671 EMERALD COAST PKWY UNIT 215
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City | MIRAMAR BEACH
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State | FL
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Zip | 32550-8304
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Country | US
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Telephone | 850-424-7170
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Fax |
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Provider Business Mailing Address
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Address Line | 12671 EMERALD COAST PKWY UNIT 215
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City | MIRAMAR BEACH
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State | FL
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Zip | 32550-8304
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Country | US
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Telephone | 850-424-7170
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Fax |
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Authorized Official
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Title or Position | PA-C
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Name | THOMAS G ROBERTS
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Credential | PA-C
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Telephone | 850-424-7170
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | ME84716
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License Number State | FL
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