Provider Demographics
NPI:1275734816
Name:GULF COAST CERTIFIED PRIMARY CARE PA
Entity Type:Organization
Organization Name:GULF COAST CERTIFIED PRIMARY CARE PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:H
Authorized Official - Last Name:JAFFE
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:239-498-5760
Mailing Address - Street 1:3384 WOODS EDGE CIR STE 103
Mailing Address - Street 2:
Mailing Address - City:BONITA SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:34134-1367
Mailing Address - Country:US
Mailing Address - Phone:239-498-5760
Mailing Address - Fax:239-498-5763
Practice Address - Street 1:3384 WOODS EDGE CIR STE 103
Practice Address - Street 2:
Practice Address - City:BONITA SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:34134-1367
Practice Address - Country:US
Practice Address - Phone:239-498-5760
Practice Address - Fax:239-498-5763
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-30
Last Update Date:2011-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS8523302R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302R00000XManaged Care OrganizationsHealth Maintenance Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLF34339Medicare UPIN
FLK3859Medicare ID - Type UnspecifiedMEDICARE NUM