Basic Information
Provider Information | |||||||||
NPI: | 1700195047 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | HANCOCK MEDICAL HEALTH SERVICES, INC. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | HANCOCK MEDICAL PASS CHRISTIAN | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 2790 | ||||||||
Address2: |   | ||||||||
City: | BAY ST LOUIS | ||||||||
State: | MS | ||||||||
PostalCode: | 395212790 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2284678700 | ||||||||
FaxNumber: | 2284678799 | ||||||||
Practice Location | |||||||||
Address1: | 517 W NORTH ST STE C&D | ||||||||
Address2: |   | ||||||||
City: | PASS CHRISTIAN | ||||||||
State: | MS | ||||||||
PostalCode: | 395712605 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2284678700 | ||||||||
FaxNumber: | 2284678799 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/05/2010 | ||||||||
LastUpdateDate: | 12/10/2013 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | SMITH | ||||||||
AuthorizedOfficialFirstName: | GUY | ||||||||
AuthorizedOfficialMiddleName: | KEN | ||||||||
AuthorizedOfficialTitleorPosition: | DIRECTOR OPERATIONS | ||||||||
AuthorizedOfficialTelephone: | 9858987091 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | MBA | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 11217 | MS | Y | 193400000X SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.