Provider Demographics
NPI:1427271840
Name:PRIMARY CARE MEDICAL CENTER OF GULFPORT, PLLC
Entity type:Organization
Organization Name:PRIMARY CARE MEDICAL CENTER OF GULFPORT, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:INSURANCE CLERK
Authorized Official - Prefix:MRS
Authorized Official - First Name:ANGELA
Authorized Official - Middle Name:V
Authorized Official - Last Name:MCCLURE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:228-832-9038
Mailing Address - Street 1:15444 DEDEAUX RD
Mailing Address - Street 2:STE. B
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39503-2637
Mailing Address - Country:US
Mailing Address - Phone:228-832-9038
Mailing Address - Fax:228-832-9990
Practice Address - Street 1:15444 DEDEAUX RD
Practice Address - Street 2:STE. B
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39503-2637
Practice Address - Country:US
Practice Address - Phone:228-832-9038
Practice Address - Fax:228-832-9990
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-11
Last Update Date:2007-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No2083X0100XAllopathic & Osteopathic PhysiciansPreventive MedicineOccupational MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MSC00324Medicare ID - Type UnspecifiedOLD TAX ID
MSC03102Medicare ID - Type UnspecifiedNEW TAX ID