Provider Demographics
NPI:1265820823
Name:PATTON MEDICAL OF THE GULF COAST, INC
Entity Type:Organization
Organization Name:PATTON MEDICAL OF THE GULF COAST, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER VP
Authorized Official - Prefix:MR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:KEITH
Authorized Official - Last Name:WADE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:228-872-8685
Mailing Address - Street 1:3002 BIENVILLE BLVD
Mailing Address - Street 2:SUITE C
Mailing Address - City:OCEAN SPRINGS
Mailing Address - State:MS
Mailing Address - Zip Code:39564-4354
Mailing Address - Country:US
Mailing Address - Phone:228-872-8685
Mailing Address - Fax:
Practice Address - Street 1:1805 OLD SHELL RD
Practice Address - Street 2:
Practice Address - City:MOBILE
Practice Address - State:AL
Practice Address - Zip Code:36607-3416
Practice Address - Country:US
Practice Address - Phone:251-459-8600
Practice Address - Fax:228-872-8686
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PATTON MEDICAL OF THE GULF COAST, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-01-06
Last Update Date:2015-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL1265820823Medicaid
AL4327600002Medicare NSC