Basic Information
| Provider Information | |||||||||
| NPI: | 1396920484 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SOUTH CENTRAL REGIONAL MEDICAL CTR | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | SOUTH CENTRAL REGIONAL MEDICAL CTR-EEG | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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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: | 1220 JEFFERSON ST | ||||||||
| Address2: | |||||||||
| City: | LAUREL | ||||||||
| State: | MS | ||||||||
| PostalCode: | 394404355 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6014264000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/08/2008 | ||||||||
| LastUpdateDate: | 11/03/2010 | ||||||||
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| AuthorizedOfficialLastName: | CANIZARO | ||||||||
| AuthorizedOfficialFirstName: | JAMES | ||||||||
| AuthorizedOfficialMiddleName: | T | ||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 6014264504 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | SOUTH CENTRAL REGIONAL MEDICAL CENTER | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 11-153 | MS | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 09013316 | 05 | MS | MEDICAID |