Provider Demographics
NPI:1164598678
Name:SUNCOAST VASCULAR CLINIC
Entity Type:Organization
Organization Name:SUNCOAST VASCULAR CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:MARC
Authorized Official - Middle Name:J
Authorized Official - Last Name:GOULET
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:954-439-3465
Mailing Address - Street 1:840 US HIGHWAY ONE #210
Mailing Address - Street 2:ATTN AMBER KENNEDY
Mailing Address - City:NORTH PALM BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33408-3830
Mailing Address - Country:US
Mailing Address - Phone:561-626-9021
Mailing Address - Fax:561-626-7593
Practice Address - Street 1:3722 CENTRAL AVE
Practice Address - Street 2:SUITE 6
Practice Address - City:FT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33901-8247
Practice Address - Country:US
Practice Address - Phone:239-277-7700
Practice Address - Fax:239-277-7070
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-27
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL50648OtherBC BS
50648AMedicare ID - Type Unspecified