| Name: | Gulf Shores Family Medicine, Inc. |
| Jurisdiction: | Alabama |
| Legal type: | Domestic Corporation |
| Status: | Dissolved |
| Date of registration: | 02 Jan 2007 (18 years ago) |
| Date of dissolution: | 21 Aug 2017 |
| Entity Number: | 000-250-595 |
| Register Number: | 000250595 |
| County: | Baldwin |
| Place of Formation: | Baldwin County |
| Principal Address: | GULF SHORES, AL |
| Registered Office Street Address: | 200 OFFICE PARK DR UNIT BGULF SHORES, AL 36542 |
| Registered Office Street Address ZIP Code: | 36542 |
| Authorized Capital: | $1,000 |
Activities
PHYSICIAN/FAMILY MEDICAL/COMMUNITY SERVICES
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1205983731 | 2007-01-05 | 2009-04-02 | P.O. BOX 1157, GULF SHORES, AL, 36547, US | 204 W 19TH AVE, GULF SHORES, AL, 36542, US | |||||||||||||||||||||||||||||
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| Phone | +1 251-968-1810 |
| Fax | 2519681817 |
Authorized person
| Name | DR. MARIROSE C. OLSON |
| Role | PRESIDENT |
| Phone | 2519681810 |
Taxonomy
| Taxonomy Code | 207Q00000X - Family Medicine Physician |
| Is Primary | No |
| Taxonomy Code | 207Q00000X - Family Medicine Physician |
| License Number | 23373 |
| State | AL |
| Is Primary | Yes |
Other Provider Identifiers
| Issuer | MEDICAID |
| Number | 9940808 |
| State | AL |
| Plan Name | Plan Year | EIN/PN | Received | Sponsor | Total number of participants | |||||||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| GULF SHORES FAMILY MEDICINE, INC. SAFE HARBOR 401(K) PROFIT SHARING PLAN | 2016 | 208048594 | 2017-07-29 | GULF SHORES FAMILY MEDICINE, INC. | 3 | |||||||||||||||||||||||||||||
|
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| Role | Plan administrator |
| Date | 2017-07-29 |
| Name of individual signing | MARIROSE TRIMMIER |
| Role | Employer/plan sponsor |
| Date | 2017-07-29 |
| Name of individual signing | MARIROSE TRIMMIER |
| File | View Page |
| Three-digit plan number (PN) | 001 |
| Effective date of plan | 2013-01-01 |
| Business code | 621111 |
| Sponsor’s telephone number | 2519681810 |
| Plan sponsor’s address | 2103 WEST FIRST STREET, GULF SHORES, AL, 36542 |
Signature of
| Role | Plan administrator |
| Date | 2016-07-24 |
| Name of individual signing | MARIROSE TRIMMIER |
| Role | Employer/plan sponsor |
| Date | 2016-07-24 |
| Name of individual signing | MARIROSE TRIMMIER |
| File | View Page |
| Three-digit plan number (PN) | 001 |
| Effective date of plan | 2013-01-01 |
| Business code | 621111 |
| Sponsor’s telephone number | 2519681810 |
| Plan sponsor’s address | 2103 WEST FIRST STREET, GULF SHORES, AL, 36542 |
Signature of
| Role | Plan administrator |
| Date | 2015-07-23 |
| Name of individual signing | MARIROSE TRIMMIER |
| Role | Employer/plan sponsor |
| Date | 2015-07-23 |
| Name of individual signing | MARIROSE TRIMMIER |
| File | View Page |
| Three-digit plan number (PN) | 001 |
| Effective date of plan | 2013-01-01 |
| Business code | 621111 |
| Sponsor’s telephone number | 2519681810 |
| Plan sponsor’s address | 2103 WEST FIRST STREET, GULF SHORES, AL, 36542 |
Signature of
| Role | Plan administrator |
| Date | 2014-09-30 |
| Name of individual signing | MARIROSE TRIMMIER |
| Name | Role |
|---|---|
| OLSON, MARIROSE C | Agent |
| Name | Role |
|---|---|
| OLSON, MARIROSE C | Incorporator |
Date of last update: 02 Aug 2024
Sources: Alabama Secretary of State
