Basic Information
| Provider Information | |||||||||
| NPI: | 1639429970 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MISISSIPPI PROVIDENCE HEALTHCARE SERVICES, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 850489 | ||||||||
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| City: | MOBILE | ||||||||
| State: | AL | ||||||||
| PostalCode: | 366850489 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2513423949 | ||||||||
| FaxNumber: | 2516313361 | ||||||||
| Practice Location | |||||||||
| Address1: | 5907 HIGHWAY 90 | ||||||||
| Address2: | |||||||||
| City: | MOSS POINT | ||||||||
| State: | MS | ||||||||
| PostalCode: | 395636536 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2287692611 | ||||||||
| FaxNumber: | 2287621638 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/13/2012 | ||||||||
| LastUpdateDate: | 01/22/2013 | ||||||||
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| AuthorizedOfficialLastName: | CHRISTIANSON | ||||||||
| AuthorizedOfficialFirstName: | CLARK | ||||||||
| AuthorizedOfficialMiddleName: | P. | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 2516313574 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | AL | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.