Provider Demographics
NPI:1700264025
Name:GULF COAST LIFE, PLLC
Entity Type:Organization
Organization Name:GULF COAST LIFE, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:ERIN
Authorized Official - Middle Name:ADAM
Authorized Official - Last Name:DEWITT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:228-255-8818
Mailing Address - Street 1:4405 E ALOHA DR
Mailing Address - Street 2:
Mailing Address - City:DIAMONDHEAD
Mailing Address - State:MS
Mailing Address - Zip Code:39525-3380
Mailing Address - Country:US
Mailing Address - Phone:228-255-8818
Mailing Address - Fax:228-255-8820
Practice Address - Street 1:4405 E ALOHA DR
Practice Address - Street 2:
Practice Address - City:DIAMONDHEAD
Practice Address - State:MS
Practice Address - Zip Code:39525-3380
Practice Address - Country:US
Practice Address - Phone:228-255-8818
Practice Address - Fax:228-255-8820
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-05-07
Last Update Date:2015-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty