Basic Information
| Provider Information | |||||||||
| NPI: | 1356672166 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | HANCOCK MEDICAL CENTER | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | HANCOCK MEDICAL WALK-IN CARE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2790 | ||||||||
| Address2: | |||||||||
| City: | BAY ST LOUIS | ||||||||
| State: | MS | ||||||||
| PostalCode: | 395212790 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2284678700 | ||||||||
| FaxNumber: | 2284678799 | ||||||||
| Practice Location | |||||||||
| Address1: | 17000 KAPALAMA DR | ||||||||
| Address2: | |||||||||
| City: | PASS CHRISTIAN | ||||||||
| State: | MS | ||||||||
| PostalCode: | 395719761 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2284678700 | ||||||||
| FaxNumber: | 2284678799 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/18/2010 | ||||||||
| LastUpdateDate: | 03/16/2010 | ||||||||
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| AuthorizedOfficialLastName: | WADE | ||||||||
| AuthorizedOfficialFirstName: | DONALD | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF FINANCIAL OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 2284678700 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | CPA | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 11217 | MS | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.