Provider Demographics
NPI:1477530657
Name:GULFPORT OBSTETRICAL & GYNECOLOGICAL CLINIC, PA
Entity Type:Organization
Organization Name:GULFPORT OBSTETRICAL & GYNECOLOGICAL CLINIC, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:P
Authorized Official - Last Name:BURKART
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:228-863-9977
Mailing Address - Street 1:4502 OLD PASS RD
Mailing Address - Street 2:
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39501-2585
Mailing Address - Country:US
Mailing Address - Phone:228-863-9977
Mailing Address - Fax:228-822-2174
Practice Address - Street 1:4502 OLD PASS RD
Practice Address - Street 2:
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39501-2585
Practice Address - Country:US
Practice Address - Phone:228-863-9977
Practice Address - Fax:228-822-2174
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-28
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS82612251B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09013169Medicaid
=========OtherMEDICAL CLINIC