Provider Demographics
NPI:1558745463
Name:GULF COAST HMA PHYSICIAN MANAGEMENT LLC
Entity Type:Organization
Organization Name:GULF COAST HMA PHYSICIAN MANAGEMENT LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SR DIR PROV ENROLLMENT
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:L
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-465-3334
Mailing Address - Street 1:1370 E VENICE AVE
Mailing Address - Street 2:STE 205
Mailing Address - City:VENICE
Mailing Address - State:FL
Mailing Address - Zip Code:34285-9082
Mailing Address - Country:US
Mailing Address - Phone:941-800-4700
Mailing Address - Fax:941-800-4711
Practice Address - Street 1:1370 E VENICE AVE
Practice Address - Street 2:STE 205
Practice Address - City:VENICE
Practice Address - State:FL
Practice Address - Zip Code:34285-9082
Practice Address - Country:US
Practice Address - Phone:941-800-4700
Practice Address - Fax:941-800-4711
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-10
Last Update Date:2022-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLND6940133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Multi-Specialty