Provider Demographics
NPI:1073653903
Name:GULF SOUTH PEDIATRIC CARDIOLOGY, LLC
Entity Type:Organization
Organization Name:GULF SOUTH PEDIATRIC CARDIOLOGY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:LISA
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:GOODWIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:228-868-7046
Mailing Address - Street 1:4500 13TH ST
Mailing Address - Street 2:611 BROAD AVENUE
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39501-2515
Mailing Address - Country:US
Mailing Address - Phone:228-868-7046
Mailing Address - Fax:228-575-2120
Practice Address - Street 1:4500 13TH ST
Practice Address - Street 2:611 BROAD AVENUE
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39501-2515
Practice Address - Country:US
Practice Address - Phone:228-868-7046
Practice Address - Fax:228-575-2120
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-08
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA=========OtherFEDERAL TAX IDENTIFICATIO
MS=========OtherFEDERALTAX IDENTIFICATION