Provider Demographics
NPI:1376532788
Name:GULF COAST DERMATOLOGY, PA
Entity Type:Organization
Organization Name:GULF COAST DERMATOLOGY, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:GWENDOLYN
Authorized Official - Middle Name:A
Authorized Official - Last Name:CRANE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:228-868-4006
Mailing Address - Street 1:1304 44TH AVE
Mailing Address - Street 2:
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39501-2552
Mailing Address - Country:US
Mailing Address - Phone:228-868-4006
Mailing Address - Fax:228-868-9545
Practice Address - Street 1:1304 44TH AVE
Practice Address - Street 2:
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39501-2552
Practice Address - Country:US
Practice Address - Phone:228-868-4006
Practice Address - Fax:228-868-9545
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-18
Last Update Date:2009-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS14316207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS04922734Medicaid
MS070007893OtherMEDICARE RR