Provider Demographics
NPI:1003238569
Name:GULF COAST OCCUPATIONAL SPORTS AND PAIN MEDICINE LLC
Entity Type:Organization
Organization Name:GULF COAST OCCUPATIONAL SPORTS AND PAIN MEDICINE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RON
Authorized Official - Middle Name:R
Authorized Official - Last Name:LEE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:251-923-2050
Mailing Address - Street 1:222 S ALSTON ST
Mailing Address - Street 2:
Mailing Address - City:FOLEY
Mailing Address - State:AL
Mailing Address - Zip Code:36535-1914
Mailing Address - Country:US
Mailing Address - Phone:251-923-2050
Mailing Address - Fax:251-923-2051
Practice Address - Street 1:222 S ALSTON ST
Practice Address - Street 2:
Practice Address - City:FOLEY
Practice Address - State:AL
Practice Address - Zip Code:36535-1914
Practice Address - Country:US
Practice Address - Phone:251-923-2050
Practice Address - Fax:251-923-2051
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-01-16
Last Update Date:2020-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL23039207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ALH06412Medicare UPIN