Provider Demographics
NPI:1790083012
Name:GAMUT MEDICAL GROUP PA
Entity Type:Organization
Organization Name:GAMUT MEDICAL GROUP PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ULYSSES
Authorized Official - Middle Name:
Authorized Official - Last Name:URQUIDI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:915-783-8162
Mailing Address - Street 1:8524 MOUNTAIN ASH DR
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79904-2442
Mailing Address - Country:US
Mailing Address - Phone:915-783-8162
Mailing Address - Fax:915-351-6601
Practice Address - Street 1:8524 MOUNTAIN ASH DR
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79904-2442
Practice Address - Country:US
Practice Address - Phone:915-783-8162
Practice Address - Fax:915-351-6601
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-03-10
Last Update Date:2011-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL4774207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty