Provider Demographics
NPI:1114695087
Name:GULF COAST HMA PHYSICIAN MANAGEMENT LLC
Entity Type:Organization
Organization Name:GULF COAST HMA PHYSICIAN MANAGEMENT LLC
Other - Org Name:GULF COAST HMA PHYSICIAN MANAGEMENT LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SR DR PROV ENROLLMENT & ONBOARDING
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:L
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-465-3334
Mailing Address - Street 1:PO BOX 689022
Mailing Address - Street 2:
Mailing Address - City:FRANKLIN
Mailing Address - State:TN
Mailing Address - Zip Code:37068-9022
Mailing Address - Country:US
Mailing Address - Phone:615-465-7211
Mailing Address - Fax:615-628-6877
Practice Address - Street 1:836 SUNSET LAKE BLVD STE 102
Practice Address - Street 2:
Practice Address - City:VENICE
Practice Address - State:FL
Practice Address - Zip Code:34292-7555
Practice Address - Country:US
Practice Address - Phone:941-497-1771
Practice Address - Fax:941-497-1860
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-09-03
Last Update Date:2022-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLPENDINGMedicaid