Provider Demographics
NPI:1093780959
Name:GULF COAST PLASTIC SURGERY
Entity Type:Organization
Organization Name:GULF COAST PLASTIC SURGERY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER MD
Authorized Official - Prefix:DR
Authorized Official - First Name:ERIC
Authorized Official - Middle Name:J
Authorized Official - Last Name:WYBLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:228-865-7299
Mailing Address - Street 1:PO BOX 366
Mailing Address - Street 2:
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39502-0366
Mailing Address - Country:US
Mailing Address - Phone:228-865-7299
Mailing Address - Fax:
Practice Address - Street 1:1133 45TH AVE
Practice Address - Street 2:
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39501-2564
Practice Address - Country:US
Practice Address - Phone:228-865-7299
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-22
Last Update Date:2009-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS12046208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MSDG9511OtherRAILROAD MEDICARE
MSDG9511OtherRAILROAD MEDICARE