Provider Demographics
NPI:1952697724
Name:GULFSIDE MEDICAL CARE LLC
Entity Type:Organization
Organization Name:GULFSIDE MEDICAL CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PA-C
Authorized Official - Prefix:
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:G
Authorized Official - Last Name:ROBERTS
Authorized Official - Suffix:
Authorized Official - Credentials:PA-C
Authorized Official - Phone:850-424-7170
Mailing Address - Street 1:12671 EMERALD COAST PKWY UNIT 215
Mailing Address - Street 2:
Mailing Address - City:MIRAMAR BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32550-8304
Mailing Address - Country:US
Mailing Address - Phone:850-424-7170
Mailing Address - Fax:
Practice Address - Street 1:12671 EMERALD COAST PKWY UNIT 215
Practice Address - Street 2:
Practice Address - City:MIRAMAR BEACH
Practice Address - State:FL
Practice Address - Zip Code:32550-8304
Practice Address - Country:US
Practice Address - Phone:850-424-7170
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-06-21
Last Update Date:2011-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME84716207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL51498HMedicare PIN