Provider Demographics
NPI:1205864857
Name:GULF COAST RADIOLOGY GROUP, PA
Entity type:Organization
Organization Name:GULF COAST RADIOLOGY GROUP, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:L
Authorized Official - Last Name:SAULS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:228-875-0171
Mailing Address - Street 1:PO BOX 1527
Mailing Address - Street 2:
Mailing Address - City:OCEAN SPRINGS
Mailing Address - State:MS
Mailing Address - Zip Code:39566-1527
Mailing Address - Country:US
Mailing Address - Phone:228-875-0171
Mailing Address - Fax:228-875-0172
Practice Address - Street 1:1151 OCEAN SPRINGS RD
Practice Address - Street 2:
Practice Address - City:OCEAN SPRINGS
Practice Address - State:MS
Practice Address - Zip Code:39564-3421
Practice Address - Country:US
Practice Address - Phone:228-875-0171
Practice Address - Fax:228-875-0172
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-30
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09013812Medicaid
MSC00446Medicare ID - Type UnspecifiedGROUP PROVIDER NUMBER