Provider Demographics
NPI:1891833299
Name:GULF COAST NEUROLOGY CENTER, PLLC
Entity Type:Organization
Organization Name:GULF COAST NEUROLOGY CENTER, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:LENNON
Authorized Official - Middle Name:E
Authorized Official - Last Name:BOWEN
Authorized Official - Suffix:IV
Authorized Official - Credentials:MD
Authorized Official - Phone:228-818-9620
Mailing Address - Street 1:3631 BIENVILLE BLVD
Mailing Address - Street 2:SUITE A
Mailing Address - City:OCEAN SPRINGS
Mailing Address - State:MS
Mailing Address - Zip Code:39564-5702
Mailing Address - Country:US
Mailing Address - Phone:228-818-9620
Mailing Address - Fax:228-818-9750
Practice Address - Street 1:3631 BIENVILLE BLVD
Practice Address - Street 2:SUITE A
Practice Address - City:OCEAN SPRINGS
Practice Address - State:MS
Practice Address - Zip Code:39564-5702
Practice Address - Country:US
Practice Address - Phone:228-818-9620
Practice Address - Fax:228-818-9750
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-01
Last Update Date:2008-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
646000515OtherCOMMERCIAL
646000515OtherCOMMERCIAL
C03764Medicare UPIN