Basic Information
| Provider Information | |||||||||
| NPI: | 1235116401 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PISCIOTTA | ||||||||
| FirstName: | MICHELE | ||||||||
| MiddleName: | Q | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PHYSICIAN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4502 OLD PASS RD | ||||||||
| Address2: | |||||||||
| City: | GULFPORT | ||||||||
| State: | MS | ||||||||
| PostalCode: | 395012585 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2288639977 | ||||||||
| FaxNumber: | 2288639912 | ||||||||
| Practice Location | |||||||||
| Address1: | 4502 OLD PASS RD | ||||||||
| Address2: | |||||||||
| City: | GULFPORT | ||||||||
| State: | MS | ||||||||
| PostalCode: | 395012585 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2288639977 | ||||||||
| FaxNumber: | 2288639912 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/28/2005 | ||||||||
| LastUpdateDate: | 07/09/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | 16374 | MS | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 00120940 | 05 | MS | MEDICAID |