Basic Information
| Provider Information | |||||||||
| NPI: | 1316016421 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WILLIAMS | ||||||||
| FirstName: | FRED | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 22 DOCTORS DR | ||||||||
| Address2: | SUITE C | ||||||||
| City: | OCEAN SPRINGS | ||||||||
| State: | MS | ||||||||
| PostalCode: | 39564 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2288180563 | ||||||||
| FaxNumber: | 2288180519 | ||||||||
| Practice Location | |||||||||
| Address1: | 4500 13TH ST | ||||||||
| Address2: | |||||||||
| City: | GULFPORT | ||||||||
| State: | MS | ||||||||
| PostalCode: | 395012515 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2288180563 | ||||||||
| FaxNumber: | 2288180519 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/06/2006 | ||||||||
| LastUpdateDate: | 03/06/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | R717916 | MS | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 00119340 | 05 | MS | MEDICAID |