Provider Demographics
NPI:1720302508
Name:GULF COAST ABC PEDIATRICS, INC.
Entity Type:Organization
Organization Name:GULF COAST ABC PEDIATRICS, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:LETICIA
Authorized Official - Last Name:GRAYSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:228-594-8000
Mailing Address - Street 1:1024 TOMMY MUNRO DRIVE, SUITE A
Mailing Address - Street 2:
Mailing Address - City:BILOXI
Mailing Address - State:MS
Mailing Address - Zip Code:39532
Mailing Address - Country:US
Mailing Address - Phone:228-594-8000
Mailing Address - Fax:228-594-8002
Practice Address - Street 1:1024 TOMMY MUNRO DR STE A
Practice Address - Street 2:
Practice Address - City:BILOXI
Practice Address - State:MS
Practice Address - Zip Code:39532-2157
Practice Address - Country:US
Practice Address - Phone:228-594-8000
Practice Address - Fax:228-594-8002
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-03-23
Last Update Date:2010-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS17609208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty