Basic Information
| Provider Information | |||||||||
| NPI: | 1255422457 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SOUTHWEST MS REGIONAL MEDICAL CENTER | ||||||||
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| OtherOrganizationName: | CARDIOVASCULAR INSTITUTE OF MS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 490 | ||||||||
| Address2: | |||||||||
| City: | MCCOMB | ||||||||
| State: | MS | ||||||||
| PostalCode: | 396490490 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6012491350 | ||||||||
| FaxNumber: | 6012491339 | ||||||||
| Practice Location | |||||||||
| Address1: | 1065 E BROAD ST | ||||||||
| Address2: | |||||||||
| City: | MONTICELLO | ||||||||
| State: | MS | ||||||||
| PostalCode: | 396547703 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6015871214 | ||||||||
| FaxNumber: | 6015874716 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/27/2006 | ||||||||
| LastUpdateDate: | 04/13/2021 | ||||||||
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| AuthorizedOfficialLastName: | ROWLEY | ||||||||
| AuthorizedOfficialFirstName: | CHARLA | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 6012491806 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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| NPICertificationDate: | 04/13/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208G00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Thoracic Surgery (Cardiothoracic Vascular Surgery) | 207RC0000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
| ID | Type | State | Issuer | Description | 09015786 | 05 | MS | MEDICAID |