Basic Information
| Provider Information | |||||||||
| NPI: | 1023067071 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SOUTHWEST MISSISSIPPI REGIONAL MEDICAL CENTER | ||||||||
| LastName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | MISSISSIPPI ORTHOPEDIC CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 490 | ||||||||
| Address2: | |||||||||
| City: | MCCOMB | ||||||||
| State: | MS | ||||||||
| PostalCode: | 396490490 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6012492701 | ||||||||
| FaxNumber: | 6012492195 | ||||||||
| Practice Location | |||||||||
| Address1: | 300 RAWLS DR STE 500 | ||||||||
| Address2: | |||||||||
| City: | MCCOMB | ||||||||
| State: | MS | ||||||||
| PostalCode: | 396482899 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6012494282 | ||||||||
| FaxNumber: | 6012494852 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/08/2006 | ||||||||
| LastUpdateDate: | 07/13/2022 | ||||||||
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| AuthorizedOfficialLastName: | ROWLEY | ||||||||
| AuthorizedOfficialFirstName: | CHARLA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 6012491806 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 07/13/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207XX0005X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Sports Medicine |
ID Information
| ID | Type | State | Issuer | Description | 03232365 | 05 | MS | MEDICAID |