Basic Information
| Provider Information | |||||||||
| NPI: | 1598776627 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SOUTH MISSISSIPPI SURGEONS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2525 TELEPHONE RD | ||||||||
| Address2: | |||||||||
| City: | PASCAGOULA | ||||||||
| State: | MS | ||||||||
| PostalCode: | 39567 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2287624483 | ||||||||
| FaxNumber: | 2287690406 | ||||||||
| Practice Location | |||||||||
| Address1: | 147 REYNOIR ST STE 201 | ||||||||
| Address2: | |||||||||
| City: | BILOXI | ||||||||
| State: | MS | ||||||||
| PostalCode: | 395304121 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2287624483 | ||||||||
| FaxNumber: | 2287690406 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/11/2006 | ||||||||
| LastUpdateDate: | 08/24/2020 | ||||||||
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| AuthorizedOfficialLastName: | DAVENPORT | ||||||||
| AuthorizedOfficialFirstName: | DONALD | ||||||||
| AuthorizedOfficialMiddleName: | S | ||||||||
| AuthorizedOfficialTitleorPosition: | OFFICE ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 2287624483 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 08/24/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | 09344 | MS | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 01571016 | 05 | MS | MEDICAID |