Provider Demographics
NPI:1376887620
Name:GULF COAST CHILDRENS CLINIC, PA
Entity Type:Organization
Organization Name:GULF COAST CHILDRENS CLINIC, PA
Other - Org Name:GULF COAST CHILDRENS CLINIC AT WIGGINS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:MEICHELLE
Authorized Official - Middle Name:
Authorized Official - Last Name:HARVEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:228-875-0780
Mailing Address - Street 1:3650 GROVELAND RD
Mailing Address - Street 2:
Mailing Address - City:OCEAN SPRINGS
Mailing Address - State:MS
Mailing Address - Zip Code:39564-5754
Mailing Address - Country:US
Mailing Address - Phone:228-875-0780
Mailing Address - Fax:228-875-1009
Practice Address - Street 1:930 MAIN STREET SUITE A
Practice Address - Street 2:
Practice Address - City:WIGGNIS
Practice Address - State:MS
Practice Address - Zip Code:39564-0000
Practice Address - Country:US
Practice Address - Phone:228-875-0780
Practice Address - Fax:228-875-1009
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GULF COAST CHILDRENS CLINIC, PA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-11-26
Last Update Date:2012-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty