Provider Demographics
NPI:1164450359
Name:GULF COAST INTERNAL MEDICINE PLLC
Entity Type:Organization
Organization Name:GULF COAST INTERNAL MEDICINE PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:MRS
Authorized Official - First Name:VALERIE
Authorized Official - Middle Name:REED
Authorized Official - Last Name:LENOX
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:228-388-0062
Mailing Address - Street 1:1721 MEDICAL PARK DR
Mailing Address - Street 2:STE 101
Mailing Address - City:BILOXI
Mailing Address - State:MS
Mailing Address - Zip Code:39532
Mailing Address - Country:US
Mailing Address - Phone:228-388-0062
Mailing Address - Fax:228-388-1701
Practice Address - Street 1:1721 MEDICAL PARK DR
Practice Address - Street 2:STE 101
Practice Address - City:BILOXI
Practice Address - State:MS
Practice Address - Zip Code:39532
Practice Address - Country:US
Practice Address - Phone:228-388-0062
Practice Address - Fax:228-388-1701
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-28
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MSR784087OtherLICENSE LEIGH DRACE
MS17319OtherLICENSE RACHEL TADLOCK
MS09015465Medicaid
MS13331OtherLICENSE VALERIE LENOX
MS16183OtherLICENSE MARILYN MORA
H23096Medicare UPIN
MS13331OtherLICENSE VALERIE LENOX
E35057Medicare UPIN
G96421Medicare UPIN
MS09015465Medicaid