Provider Demographics
NPI:1053463034
Name:PIONEER MEDICAL CENTER LLP
Entity Type:Organization
Organization Name:PIONEER MEDICAL CENTER LLP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:MR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:STEPHEN
Authorized Official - Last Name:GOSSMAN
Authorized Official - Suffix:
Authorized Official - Credentials:PHYSICIAN ASSISTANT
Authorized Official - Phone:863-773-6606
Mailing Address - Street 1:515 CARLTON STREET
Mailing Address - Street 2:
Mailing Address - City:WAUCHULA
Mailing Address - State:FL
Mailing Address - Zip Code:33873
Mailing Address - Country:US
Mailing Address - Phone:863-773-6606
Mailing Address - Fax:863-773-9542
Practice Address - Street 1:515 CARLTON STREET
Practice Address - Street 2:
Practice Address - City:WAUCHULA
Practice Address - State:FL
Practice Address - Zip Code:33873
Practice Address - Country:US
Practice Address - Phone:863-773-6606
Practice Address - Fax:863-773-9542
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-18
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
103831Medicare ID - Type Unspecified