Provider Demographics
NPI:1891354007
Name:GULF COAST PAIN CONSULTANTS LLC
Entity Type:Organization
Organization Name:GULF COAST PAIN CONSULTANTS LLC
Other - Org Name:CLEARWAY PAIN SOLUTIONS INSTITUTE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:KACEY
Authorized Official - Middle Name:A
Authorized Official - Last Name:MONTGOMERY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:850-791-6895
Mailing Address - Street 1:201 DEFENSE HWY STE 205
Mailing Address - Street 2:
Mailing Address - City:ANNAPOLIS
Mailing Address - State:MD
Mailing Address - Zip Code:21401-7096
Mailing Address - Country:US
Mailing Address - Phone:855-527-7246
Mailing Address - Fax:833-810-1165
Practice Address - Street 1:1600 JENKS AVE STE 2
Practice Address - Street 2:
Practice Address - City:PANAMA CITY
Practice Address - State:FL
Practice Address - Zip Code:32405-4740
Practice Address - Country:US
Practice Address - Phone:850-484-4080
Practice Address - Fax:850-484-8801
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-06-11
Last Update Date:2023-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain MedicineGroup - Multi-Specialty
No261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory SurgicalGroup - Multi-Specialty