Provider Demographics
NPI:1740291145
Name:GULFPORT SURGERY CLINIC
Entity type:Organization
Organization Name:GULFPORT SURGERY CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:PAUL
Authorized Official - Last Name:MACE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:228-822-6160
Mailing Address - Street 1:1312 44TH AVE
Mailing Address - Street 2:
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39501-2552
Mailing Address - Country:US
Mailing Address - Phone:228-822-6160
Mailing Address - Fax:228-539-8327
Practice Address - Street 1:1312 44TH AVE
Practice Address - Street 2:
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39501-2552
Practice Address - Country:US
Practice Address - Phone:228-822-6160
Practice Address - Fax:228-539-8327
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-10
Last Update Date:2020-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS13995174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00383374Medicaid
MS00383374Medicaid
MSF84483Medicare UPIN