Provider Demographics
NPI:1992154025
Name:GULF COAST CHILDREN'S CLINIC
Entity type:Organization
Organization Name:GULF COAST CHILDREN'S CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:MEICHELLE
Authorized Official - Middle Name:
Authorized Official - Last Name:HARVEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:228-875-0780
Mailing Address - Street 1:1720A MEDICAL PARK DR
Mailing Address - Street 2:SUITE 200
Mailing Address - City:BILOXI
Mailing Address - State:MS
Mailing Address - Zip Code:39532-2129
Mailing Address - Country:US
Mailing Address - Phone:228-396-2726
Mailing Address - Fax:228-875-1009
Practice Address - Street 1:3650 GROVELAND RD
Practice Address - Street 2:
Practice Address - City:OCEAN SPRINGS
Practice Address - State:MS
Practice Address - Zip Code:39564-5754
Practice Address - Country:US
Practice Address - Phone:228-875-0780
Practice Address - Fax:228-875-1009
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-06-09
Last Update Date:2016-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS05258597Medicaid