Provider Demographics
NPI:1205850773
Name:GULF COAST IMAGING
Entity Type:Organization
Organization Name:GULF COAST IMAGING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:O
Authorized Official - Last Name:HENRY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:228-314-7226
Mailing Address - Street 1:PO BOX 2819
Mailing Address - Street 2:
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39505-2819
Mailing Address - Country:US
Mailing Address - Phone:228-314-7226
Mailing Address - Fax:228-314-7227
Practice Address - Street 1:14245 DEDEAUX RD
Practice Address - Street 2:
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39503-3369
Practice Address - Country:US
Practice Address - Phone:228-314-7226
Practice Address - Fax:228-314-7227
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-27
Last Update Date:2013-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS10410Medicaid
MS03733573Medicaid
1154338879OtherDR DIANNA RAGULA
MS16169Medicaid
MSD66550Medicare UPIN
H28243Medicare UPIN
MSE04465Medicare UPIN
MS300000193Medicare ID - Type UnspecifiedDR HENRY
MS03733573Medicaid
300000871Medicare PIN