MEDICARE: GULF COAST NEUROLOGY CENTER, PLLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2084N0400X	Neurology Physician

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	646000515	OTHER		COMMERCIAL

General Provider Information

NPI Number	:	1891833299
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GULF COAST NEUROLOGY CENTER, PLLC

Provider Business Mailing Address
First Line	:	3631 BIENVILLE BLVD
Second Line	:	SUITE A
City	:	OCEAN SPRINGS
State	:	MS
Zip	:	39564-5702
Country	:	US
Telephone Number	:	228-818-9620
Fax Number	:	228-818-9750

Provider Business Practice Location Address
First Line	:	3631 BIENVILLE BLVD
Second Line	:	SUITE A
City	:	OCEAN SPRINGS
State	:	MS
Zip	:	39564-5702
Country	:	US
Telephone Number	:	228-818-9620
Fax Number	:	228-818-9750

Authorized Official
Title or Position	:	MANAGER
Name	:	DR. LENNON E BOWEN IV
Credential	:	M.D.
Telephone Number	:	228-818-9620

Provider Enumeration Date	:	02/01/2007
Last Update Date	:	05/23/2008

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