Provider Demographics
NPI:1285679050
Name:GULF COAST MEDICAL CENTER PRIMARY CARE LLC
Entity Type:Organization
Organization Name:GULF COAST MEDICAL CENTER PRIMARY CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP
Authorized Official - Prefix:
Authorized Official - First Name:MICKEY
Authorized Official - Middle Name:
Authorized Official - Last Name:PICKLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:850-229-8288
Mailing Address - Street 1:2202 STATE AVE
Mailing Address - Street 2:STE. 207
Mailing Address - City:PANAMA CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32405-7601
Mailing Address - Country:US
Mailing Address - Phone:850-784-2645
Mailing Address - Fax:850-784-2646
Practice Address - Street 1:2202 STATE AVE
Practice Address - Street 2:STE. 207
Practice Address - City:PANAMA CITY
Practice Address - State:FL
Practice Address - Zip Code:32405-7601
Practice Address - Country:US
Practice Address - Phone:850-784-2645
Practice Address - Fax:850-784-2646
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-17
Last Update Date:2011-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLK9625Medicare PIN