Provider Demographics
NPI:1679668958
Name:GARDEN PARK PHYSICIAN GROUP-SPECIALTY CARE, LLC
Entity Type:Organization
Organization Name:GARDEN PARK PHYSICIAN GROUP-SPECIALTY CARE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP
Authorized Official - Prefix:MR
Authorized Official - First Name:TODD
Authorized Official - Middle Name:
Authorized Official - Last Name:CARLON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:816-508-4090
Mailing Address - Street 1:15190 COMMUNITY RD
Mailing Address - Street 2:SUITE 330
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39503-3485
Mailing Address - Country:US
Mailing Address - Phone:228-539-9100
Mailing Address - Fax:228-539-9133
Practice Address - Street 1:15190 COMMUNITY RD
Practice Address - Street 2:SUITE 330
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39503-3485
Practice Address - Country:US
Practice Address - Phone:228-539-9100
Practice Address - Fax:228-539-9133
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-04
Last Update Date:2013-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS3576014Medicaid
MS01681729Medicaid
MSC03700Medicare PIN
DG5132Medicare PIN