Provider Demographics
NPI:1184049561
Name:GULF COAST INTERVENTIONAL PAIN MANAGEMENT CLINIC, INC
Entity type:Organization
Organization Name:GULF COAST INTERVENTIONAL PAIN MANAGEMENT CLINIC, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SHAWN
Authorized Official - Middle Name:XUN
Authorized Official - Last Name:MEI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:228-284-1642
Mailing Address - Street 1:11010 DAVID ST
Mailing Address - Street 2:SUITE B
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39503-3481
Mailing Address - Country:US
Mailing Address - Phone:228-284-1642
Mailing Address - Fax:228-284-1643
Practice Address - Street 1:11010 DAVID ST
Practice Address - Street 2:SUITE B
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39503-3481
Practice Address - Country:US
Practice Address - Phone:228-284-1642
Practice Address - Fax:228-284-1643
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-02-21
Last Update Date:2014-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSBM8022149305S00000X
MS18456305S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305S00000XManaged Care OrganizationsPoint of Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
MSYJ8HMedicare UPIN