Basic Information
Provider Information | |||||||||
NPI: | 1649329475 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | SOUTH CENTRAL REGIONAL MEDICAL CENTER | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | SOUTH CENTRAL REG MED CTR-MNT | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 607 | ||||||||
Address2: |   | ||||||||
City: | LAUREL | ||||||||
State: | MS | ||||||||
PostalCode: | 394410607 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6014264000 | ||||||||
FaxNumber: | 6013996254 | ||||||||
Practice Location | |||||||||
Address1: | 1220 JEFFERSON ST | ||||||||
Address2: |   | ||||||||
City: | LAUREL | ||||||||
State: | MS | ||||||||
PostalCode: | 394404355 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6014264000 | ||||||||
FaxNumber: | 6013996254 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/10/2007 | ||||||||
LastUpdateDate: | 11/03/2010 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | CANIZARO | ||||||||
AuthorizedOfficialFirstName: | JAMES | ||||||||
AuthorizedOfficialMiddleName: | T | ||||||||
AuthorizedOfficialTitleorPosition: | CFO | ||||||||
AuthorizedOfficialTelephone: | 6014264504 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | SOUTH CENTRAL REGIONAL MEDICAL CENTER | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133V00000X | 11-153 | MS | Y | 193400000X SINGLE SPECIALTY GROUP | Dietary & Nutritional Service Providers | Dietitian, Registered |   |
ID Information
ID | Type | State | Issuer | Description | 08759070 | 05 | MS |   | MEDICAID | 512G700476 | 01 | MS | MEDICARE PTAN | OTHER | 000019141 | 01 | MS | BLUE CROSS OF MS | OTHER |