Provider Demographics
NPI:1093121196
Name:GULF COAST OUTPATIENT SURGERY CENTER, LLC
Entity Type:Organization
Organization Name:GULF COAST OUTPATIENT SURGERY CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:LEAH
Authorized Official - Middle Name:
Authorized Official - Last Name:ETHRIDGE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:228-297-0517
Mailing Address - Street 1:2781 CT SENIOR SWITZER DRIVE
Mailing Address - Street 2:SUITE 101
Mailing Address - City:BILOXI
Mailing Address - State:MS
Mailing Address - Zip Code:39531
Mailing Address - Country:US
Mailing Address - Phone:228-594-2900
Mailing Address - Fax:
Practice Address - Street 1:2781 CT SENIOR SWITZER DRIVE
Practice Address - Street 2:SUITE 101
Practice Address - City:BILOXI
Practice Address - State:MS
Practice Address - Zip Code:39531
Practice Address - Country:US
Practice Address - Phone:228-594-2900
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-07-09
Last Update Date:2014-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS022261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS01079220Medicaid
MS490000042OtherMEDICARE PTAN