Basic Information
| Provider Information | |||||||||
| NPI: | 1487327193 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SINGING RIVER GULFPORT | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | SINGING RIVER GULFPORT INPATIENT PHYSICIAN SERVICES | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2101 HIGHWAY 90 | ||||||||
| Address2: | |||||||||
| City: | GAUTIER | ||||||||
| State: | MS | ||||||||
| PostalCode: | 395535340 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2284977576 | ||||||||
| FaxNumber: | 2284978869 | ||||||||
| Practice Location | |||||||||
| Address1: | 15200 COMMUNITY RD | ||||||||
| Address2: | |||||||||
| City: | GULFPORT | ||||||||
| State: | MS | ||||||||
| PostalCode: | 395033085 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2285757112 | ||||||||
| FaxNumber: | 2285757190 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/28/2021 | ||||||||
| LastUpdateDate: | 08/26/2022 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | WILLIAMS | ||||||||
| AuthorizedOfficialFirstName: | JANET | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PROVIDER SERVICES SPECIALIST | ||||||||
| AuthorizedOfficialTelephone: | 2284977576 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 08/26/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | N | Nursing & Custodial Care Facilities | Skilled Nursing Facility | 207R00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 09833721 | 05 | MS | MEDICAID |