Provider Demographics
NPI:1366922023
Name:PHYSICIAN SERVICES OF THE GULF COAST LLC
Entity type:Organization
Organization Name:PHYSICIAN SERVICES OF THE GULF COAST LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:
Authorized Official - Last Name:LOUKATOS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:228-396-3945
Mailing Address - Street 1:PO BOX 7417
Mailing Address - Street 2:
Mailing Address - City:DIBERVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:39540-7401
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:921 CEDAR LAKE RD STE E
Practice Address - Street 2:
Practice Address - City:BILOXI
Practice Address - State:MS
Practice Address - Zip Code:39532-2126
Practice Address - Country:US
Practice Address - Phone:228-396-3945
Practice Address - Fax:228-396-3946
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-08-21
Last Update Date:2023-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS261QU0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care