Provider Demographics
NPI:1255501268
Name:GULF SHORE INTERNAL MEDICINE, P.A.
Entity Type:Organization
Organization Name:GULF SHORE INTERNAL MEDICINE, P.A.
Other - Org Name:RODERICK NASSIF, D.O., P.A.
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OFFICE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:LISA
Authorized Official - Middle Name:
Authorized Official - Last Name:NASSIF
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:561-386-0600
Mailing Address - Street 1:PO BOX 9279
Mailing Address - Street 2:
Mailing Address - City:JUPITER
Mailing Address - State:FL
Mailing Address - Zip Code:33468-9279
Mailing Address - Country:US
Mailing Address - Phone:239-440-6456
Mailing Address - Fax:239-236-0337
Practice Address - Street 1:9371 CYPRESS LAKE DR STE 12
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33919-4995
Practice Address - Country:US
Practice Address - Phone:239-440-6456
Practice Address - Fax:239-236-0337
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-05
Last Update Date:2024-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS8532207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
DF4682OtherPALMETTO GBA GROUP
FLK9799OtherMEDICARE GROUP