Basic Information
| Provider Information | |||||||||
| NPI: | 1417545922 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | FORREST GENERAL HOSPITAL | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6051 U S HIGHWAY 49 | ||||||||
| Address2: | |||||||||
| City: | HATTIESBURG | ||||||||
| State: | MS | ||||||||
| PostalCode: | 394017200 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6012887000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 415 S 28TH AVE | ||||||||
| Address2: | |||||||||
| City: | HATTIESBURG | ||||||||
| State: | MS | ||||||||
| PostalCode: | 394017283 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6012646000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/10/2021 | ||||||||
| LastUpdateDate: | 01/13/2021 | ||||||||
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| AuthorizedOfficialLastName: | PARKER | ||||||||
| AuthorizedOfficialFirstName: | JACOB | ||||||||
| AuthorizedOfficialMiddleName: | CORNELIUS | ||||||||
| AuthorizedOfficialTitleorPosition: | SPECIALIST TECHNOLOGIST | ||||||||
| AuthorizedOfficialTelephone: | 6012646000 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | PROF. | ||||||||
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| AuthorizedOfficialCredential: | DO MD PHD | ||||||||
| NPICertificationDate: | 01/13/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 111NS0005X | N | 193400000X SINGLE SPECIALTY GROUP | Chiropractic Providers | Chiropractor | Sports Physician | 291U00000X | Y | Laboratories | Clinical Medical Laboratory |
ID Information
| ID | Type | State | Issuer | Description | 84-2004221-3 | 01 | VA | ZOHO HEALTHCARE PROVIDER | OTHER |