Basic Information
| Provider Information | |||||||||
| NPI: | 1689624090 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SOUTHWEST MISSISSIPPI REGIONAL MEDICAL CENTER | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | SMRMC-INTERNAL MEDICINE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 300 MARION AVE | ||||||||
| Address2: | SUITE C | ||||||||
| City: | MCCOMB | ||||||||
| State: | MS | ||||||||
| PostalCode: | 396482707 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6012491350 | ||||||||
| FaxNumber: | 6012492226 | ||||||||
| Practice Location | |||||||||
| Address1: | 300 MARION AVE | ||||||||
| Address2: | SUITE C | ||||||||
| City: | MCCOMB | ||||||||
| State: | MS | ||||||||
| PostalCode: | 396482707 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6012491350 | ||||||||
| FaxNumber: | 6012492226 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/10/2006 | ||||||||
| LastUpdateDate: | 10/12/2007 | ||||||||
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| AuthorizedOfficialLastName: | SINCLAIR | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 6012492701 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 09014058 | 05 | MS | MEDICAID |