Provider Demographics
NPI:1346819729
Name:GULF COAST HMA PHYSICIAN MANAGEMENT LLC
Entity Type:Organization
Organization Name:GULF COAST HMA PHYSICIAN MANAGEMENT LLC
Other - Org Name:GULF COAST HMA PHYSICIAN MANAGEMENT LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SR DIR PROV ENROLLMENT & ONBOARDING
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:L
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-465-3334
Mailing Address - Street 1:PO BOX 689022
Mailing Address - Street 2:
Mailing Address - City:FRANKLIN
Mailing Address - State:TN
Mailing Address - Zip Code:37068-9022
Mailing Address - Country:US
Mailing Address - Phone:615-465-7211
Mailing Address - Fax:615-628-6877
Practice Address - Street 1:8383 S TAMIAMI TRL UNIT 115
Practice Address - Street 2:
Practice Address - City:SARASOTA
Practice Address - State:FL
Practice Address - Zip Code:34238-2901
Practice Address - Country:US
Practice Address - Phone:941-244-9430
Practice Address - Fax:941-244-9437
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-06-21
Last Update Date:2022-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & MetabolismGroup - Single Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
No2083B0002XAllopathic & Osteopathic PhysiciansPreventive MedicineObesity MedicineGroup - Single Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL277033414Medicaid