Provider Demographics
NPI:1699868711
Name:GORDON T COUCH MD
Entity type:Organization
Organization Name:GORDON T COUCH MD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:MR
Authorized Official - First Name:GORDON
Authorized Official - Middle Name:THAMES
Authorized Official - Last Name:COUCH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:850-477-2330
Mailing Address - Street 1:4900 BAYOU BLVD
Mailing Address - Street 2:STE 104
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32503-2533
Mailing Address - Country:US
Mailing Address - Phone:850-477-2330
Mailing Address - Fax:850-484-8733
Practice Address - Street 1:4900 BAYOU BLVD
Practice Address - Street 2:STE 104
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32503-2533
Practice Address - Country:US
Practice Address - Phone:850-477-2330
Practice Address - Fax:850-484-8733
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-02
Last Update Date:2013-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0013562207VG0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
17215OtherBCBS
=========32503A001OtherTRICARE
=========32503A001OtherTRICARE
FLK1227Medicare PIN