Provider Demographics
NPI: | 1811569353 |
---|---|
Name: | GULF COAST HMA PHYSICIAN MANAGEMENT LLC |
Entity Type: | Organization |
Organization Name: | GULF COAST HMA PHYSICIAN MANAGEMENT LLC |
Other - Org Name: | GULF COAST HMA PHYSICIAN MANAGEMENT LLC |
Other - Org Type: | Doing Business As |
Authorized Official - Title/Position: | SR DIR PROV ENROLLMENT & ONBOARDING |
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: | PO BOX 689022 |
Mailing Address - Street 2: | |
Mailing Address - City: | FRANKLIN |
Mailing Address - State: | TN |
Mailing Address - Zip Code: | 37068-9022 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 615-465-7211 |
Mailing Address - Fax: | 615-628-6877 |
Practice Address - Street 1: | 333 TAMIAMI TRL S STE 101 |
Practice Address - Street 2: | |
Practice Address - City: | VENICE |
Practice Address - State: | FL |
Practice Address - Zip Code: | 34285-2425 |
Practice Address - Country: | US |
Practice Address - Phone: | 941-483-7651 |
Practice Address - Fax: | 941-483-7699 |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2021-07-14 |
Last Update Date: | 2022-03-15 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 207RP1001X | Allopathic & Osteopathic Physicians | Internal Medicine | Pulmonary Disease | Group - Single Specialty |
No | 207L00000X | Allopathic & Osteopathic Physicians | Anesthesiology | Group - Single Specialty | |
No | 207Q00000X | Allopathic & Osteopathic Physicians | Family Medicine | Group - Single Specialty | |
No | 207RE0101X | Allopathic & Osteopathic Physicians | Internal Medicine | Endocrinology, Diabetes & Metabolism | Group - Single Specialty |
No | 2083B0002X | Allopathic & Osteopathic Physicians | Preventive Medicine | Obesity Medicine | Group - Single Specialty |
No | 2085R0204X | Allopathic & Osteopathic Physicians | Radiology | Vascular & Interventional Radiology | Group - Single Specialty |
No | 208VP0000X | Allopathic & Osteopathic Physicians | Pain Medicine | Pain Medicine | Group - Single Specialty |
No | 213ES0103X | Podiatric Medicine & Surgery Service Providers | Podiatrist | Foot & Ankle Surgery | Group - Single Specialty |
No | 225200000X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapy Assistant | Group - Single Specialty | |
No | 363A00000X | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Group - Single Specialty | |
No | 363L00000X | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Group - Single Specialty | |
No | 363LF0000X | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | Group - Single Specialty |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
FL | 277033424 | Medicaid |