Basic Information
| Provider Information | |||||||||
| NPI: | 1134762610 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SOUTH CENTRAL REGIONAL MEDICAL CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 607 | ||||||||
| Address2: | |||||||||
| City: | LAUREL | ||||||||
| State: | MS | ||||||||
| PostalCode: | 394410607 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6013996103 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1203 JEFFERSON ST | ||||||||
| Address2: | |||||||||
| City: | LAUREL | ||||||||
| State: | MS | ||||||||
| PostalCode: | 394404354 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6015187054 | ||||||||
| FaxNumber: | 6013996254 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/28/2019 | ||||||||
| LastUpdateDate: | 10/28/2019 | ||||||||
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| AuthorizedOfficialLastName: | HICKS | ||||||||
| AuthorizedOfficialFirstName: | JUDY | ||||||||
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| AuthorizedOfficialTitleorPosition: | REVENUE CYCLE ANALYST | ||||||||
| AuthorizedOfficialTelephone: | 6013996105 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | SOUTH CENTRAL REGIONAL MEDICAL CENTER | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RH0003X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology & Oncology |
ID Information
| ID | Type | State | Issuer | Description | 07579791 | 05 | MS | MEDICAID |