Provider Demographics
NPI:1417237785
Name:GULF COAST MOBILE MEDICINE, LLC
Entity Type:Organization
Organization Name:GULF COAST MOBILE MEDICINE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:MR
Authorized Official - First Name:MARC
Authorized Official - Middle Name:E
Authorized Official - Last Name:MCCOLLAUM
Authorized Official - Suffix:
Authorized Official - Credentials:PA-C
Authorized Official - Phone:239-455-8048
Mailing Address - Street 1:8655 IBIS COVE CIR
Mailing Address - Street 2:
Mailing Address - City:NAPLES
Mailing Address - State:FL
Mailing Address - Zip Code:34119-7728
Mailing Address - Country:US
Mailing Address - Phone:239-455-8047
Mailing Address - Fax:239-455-8048
Practice Address - Street 1:8655 IBIS COVE CIR
Practice Address - Street 2:
Practice Address - City:NAPLES
Practice Address - State:FL
Practice Address - Zip Code:34119-7728
Practice Address - Country:US
Practice Address - Phone:239-455-8047
Practice Address - Fax:239-455-8048
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-08-18
Last Update Date:2011-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9102277363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
Q28860Medicare UPIN
FLU3802WMedicare PIN