Basic Information
| Provider Information | |||||||||
| NPI: | 1003007006 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | HANCOCK MEDICAL CENTER | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | DIAMONDMED URGENT CARE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | P.O. BOX 2790 | ||||||||
| Address2: | |||||||||
| City: | BAY SAINT LOUIS | ||||||||
| State: | MS | ||||||||
| PostalCode: | 395212790 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2284678700 | ||||||||
| FaxNumber: | 2284678799 | ||||||||
| Practice Location | |||||||||
| Address1: | 4540 SHEPHERD SQUARE | ||||||||
| Address2: | SUITE B | ||||||||
| City: | DIAMONDHEAD | ||||||||
| State: | MS | ||||||||
| PostalCode: | 39525 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2282558216 | ||||||||
| FaxNumber: | 2282558219 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/05/2007 | ||||||||
| LastUpdateDate: | 10/08/2009 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | WADE | ||||||||
| AuthorizedOfficialFirstName: | DONALD | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF FINANCIAL OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 2284678700 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | HANCOCK MEDICAL CENTER | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | CPA | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QU0200X | 11214 | MS | Y | Ambulatory Health Care Facilities | Clinic/Center | Urgent Care |
No ID Information.