Provider Demographics
NPI:1316677511
Name:GULF COAST SPECIALTY PROVIDERS, PLLC
Entity type:Organization
Organization Name:GULF COAST SPECIALTY PROVIDERS, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:WADE
Authorized Official - Middle Name:
Authorized Official - Last Name:KORDONOWY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:713-852-1762
Mailing Address - Street 1:2000 HEALTH PARK DR
Mailing Address - Street 2:
Mailing Address - City:BRENTWOOD
Mailing Address - State:TN
Mailing Address - Zip Code:37027-4692
Mailing Address - Country:US
Mailing Address - Phone:615-372-5426
Mailing Address - Fax:
Practice Address - Street 1:6560 FANNIN ST STE 1404
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77030-2706
Practice Address - Country:US
Practice Address - Phone:713-790-0600
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-06-13
Last Update Date:2022-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208C00000XAllopathic & Osteopathic PhysiciansColon & Rectal SurgeryGroup - Multi-Specialty