Basic Information
| Provider Information | |||||||||
| NPI: | 1487253407 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | OCHSNER MISSISSIPPI, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 149 DRINKWATER RD | ||||||||
| Address2: | |||||||||
| City: | BAY SAINT LOUIS | ||||||||
| State: | MS | ||||||||
| PostalCode: | 395201658 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 906 SIXTH AVE | ||||||||
| Address2: | |||||||||
| City: | PICAYUNE | ||||||||
| State: | MS | ||||||||
| PostalCode: | 394663802 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6017987529 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/21/2020 | ||||||||
| LastUpdateDate: | 10/21/2020 | ||||||||
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| AuthorizedOfficialLastName: | BENITEZ | ||||||||
| AuthorizedOfficialFirstName: | EDUARDO | ||||||||
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| AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 5044300025 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | OCHSNER MISSISSIPPI, LLC | ||||||||
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| NPICertificationDate: | 10/19/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 09627255 | 01 | MS | MEDICAID | OTHER |