Provider Demographics
NPI:1437113057
Name:GULF COAST IMMEDIATE CARE CENTER INC.
Entity Type:Organization
Organization Name:GULF COAST IMMEDIATE CARE CENTER INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:V
Authorized Official - Last Name:SIEGEL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:850-244-3211
Mailing Address - Street 1:345 MIRACLE STRIP PKWY SW
Mailing Address - Street 2:
Mailing Address - City:FORT WALTON BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32548-5210
Mailing Address - Country:US
Mailing Address - Phone:850-244-3211
Mailing Address - Fax:850-243-1992
Practice Address - Street 1:345 MIRACLE STRIP PKWY SW
Practice Address - Street 2:
Practice Address - City:FORT WALTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:32548-5210
Practice Address - Country:US
Practice Address - Phone:850-244-3211
Practice Address - Fax:850-243-1992
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-12
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL0602460261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
D52715Medicare UPIN
97435Medicare ID - Type UnspecifiedMEDICARE #