Basic Information
| Provider Information | |||||||||
| NPI: | 1053750125 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ANDERSON REGIONAL MEDICAL CENTER | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | AIRPARK FAMILY MEDICAL CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 2124 14TH ST | ||||||||
| Address2: | |||||||||
| City: | MERIDIAN | ||||||||
| State: | MS | ||||||||
| PostalCode: | 393014040 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6017033480 | ||||||||
| FaxNumber: | 6017030124 | ||||||||
| Practice Location | |||||||||
| Address1: | 1056 HOLLAND AVE | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | MS | ||||||||
| PostalCode: | 393509121 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6016568545 | ||||||||
| FaxNumber: | 6016563985 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/21/2013 | ||||||||
| LastUpdateDate: | 06/03/2014 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | ANDERSON | ||||||||
| AuthorizedOfficialFirstName: | JOHN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | VP | ||||||||
| AuthorizedOfficialTelephone: | 6017035010 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR1300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
ID Information
| ID | Type | State | Issuer | Description | 09014742 | 05 | MS | MEDICAID |