Basic Information
| Provider Information | |||||||||
| NPI: | 1497086607 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | REGIONAL DIGESTIVE SPECIALISTS, P.C. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4511 HOSPITAL ST | ||||||||
| Address2: | |||||||||
| City: | PASCAGOULA | ||||||||
| State: | MS | ||||||||
| PostalCode: | 395815336 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2287697791 | ||||||||
| FaxNumber: | 2287697747 | ||||||||
| Practice Location | |||||||||
| Address1: | 1721 MEDICAL PARK DR | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | BILOXI | ||||||||
| State: | MS | ||||||||
| PostalCode: | 395322109 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2283921686 | ||||||||
| FaxNumber: | 2283921738 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/28/2010 | ||||||||
| LastUpdateDate: | 06/04/2013 | ||||||||
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| AuthorizedOfficialLastName: | LOGAN | ||||||||
| AuthorizedOfficialFirstName: | BRIDGET | ||||||||
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| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 2288753033 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RG0100X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology |
ID Information
| ID | Type | State | Issuer | Description | 06023748 | 05 | MS | MEDICAID |