Provider Demographics
NPI:1700137205
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:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:SHAWN
Authorized Official - Middle Name:X
Authorized Official - Last Name:MEI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:228-284-1642
Mailing Address - Street 1:15164 DEDEAUX RD STE B
Mailing Address - Street 2:
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39503-3124
Mailing Address - Country:US
Mailing Address - Phone:228-284-1642
Mailing Address - Fax:228-284-1643
Practice Address - Street 1:15164 DEDEAUX RD STE B
Practice Address - Street 2:
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39503-3124
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:2012-09-24
Last Update Date:2018-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS18456207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS1407912223OtherNPI
MS1407912223OtherNPI