Provider Demographics
NPI:1710049200
Name:GULFSHORE MEDICAL CONSULTANTS, PA
Entity Type:Organization
Organization Name:GULFSHORE MEDICAL CONSULTANTS, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:GARY
Authorized Official - Middle Name:M
Authorized Official - Last Name:RODBERG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:228-872-1951
Mailing Address - Street 1:22A DOCTORS DR
Mailing Address - Street 2:
Mailing Address - City:OCEAN SPRINGS
Mailing Address - State:MS
Mailing Address - Zip Code:39564-5721
Mailing Address - Country:US
Mailing Address - Phone:228-872-1951
Mailing Address - Fax:228-875-9998
Practice Address - Street 1:22A DOCTORS DR
Practice Address - Street 2:
Practice Address - City:OCEAN SPRINGS
Practice Address - State:MS
Practice Address - Zip Code:39564-5721
Practice Address - Country:US
Practice Address - Phone:228-872-1951
Practice Address - Fax:228-875-9998
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-14
Last Update Date:2008-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS14252207RC0200X, 207RP1001X, 207RS0012X
MS18516207RC0200X, 207RP1001X
MS17943207RC0200X, 207RP1001X, 207RS0012X
MS15014207RR0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care MedicineGroup - Multi-Specialty
No207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary DiseaseGroup - Multi-Specialty
No207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatologyGroup - Multi-Specialty
No207RS0012XAllopathic & Osteopathic PhysiciansInternal MedicineSleep MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00114969Medicaid
MS00126926Medicaid
MS09015817Medicaid
MS00117171Medicaid
MS07521804Medicaid
MS00117171Medicaid
MSH56102Medicare UPIN
MSF97896Medicare UPIN
MSC02504Medicare ID - Type UnspecifiedMEDICARE GROUP #
MSG31289Medicare UPIN