Provider Demographics
NPI:1588952857
Name:GULF COAST DERMATOLOGY AND SKIN CARE CENTRE PLLC
Entity type:Organization
Organization Name:GULF COAST DERMATOLOGY AND SKIN CARE CENTRE PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:W
Authorized Official - Last Name:BENDER
Authorized Official - Suffix:III
Authorized Official - Credentials:MD
Authorized Official - Phone:251-631-3570
Mailing Address - Street 1:6701 AIRPORT BLVD
Mailing Address - Street 2:SUITE D232
Mailing Address - City:MOBILE
Mailing Address - State:AL
Mailing Address - Zip Code:36608-6705
Mailing Address - Country:US
Mailing Address - Phone:251-631-3570
Mailing Address - Fax:251-631-3572
Practice Address - Street 1:29653 ANCHOR CROSS BLVD
Practice Address - Street 2:
Practice Address - City:DAPHNE
Practice Address - State:AL
Practice Address - Zip Code:36526-9594
Practice Address - Country:US
Practice Address - Phone:251-631-3570
Practice Address - Fax:251-631-3572
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-07-20
Last Update Date:2013-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL21520207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL1750614301Medicaid
AL102G707171Medicare PIN