Provider Demographics
NPI:1114125606
Name:GULF COAST INTERNAL MEDICINE PA
Entity Type:Organization
Organization Name:GULF COAST INTERNAL MEDICINE PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TANZEEN
Authorized Official - Middle Name:
Authorized Official - Last Name:AHMED
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:239-986-0259
Mailing Address - Street 1:PO BOX 6038
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33911-6038
Mailing Address - Country:US
Mailing Address - Phone:239-561-8880
Mailing Address - Fax:239-561-8890
Practice Address - Street 1:14131 METROPOLIS AVENUE
Practice Address - Street 2:SUITE 106
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33912-9383
Practice Address - Country:US
Practice Address - Phone:239-561-8880
Practice Address - Fax:239-561-8890
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-05
Last Update Date:2009-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME81543174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLK9535Medicare ID - Type UnspecifiedMCARE GRP