Basic Information
| Provider Information | |||||||||
| NPI: | 1821204108 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | NATCHEZ THORACIC,VASCULAR AND SURGERY CLINIC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | NATCHEZ REGIONAL MEDICAL CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 14149 | ||||||||
| Address2: | |||||||||
| City: | BATON ROUGE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 708984149 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2259249827 | ||||||||
| FaxNumber: | 2259249829 | ||||||||
| Practice Location | |||||||||
| Address1: | 46 SERGEANT PRENTISS DR | ||||||||
| Address2: | SUITE 203 | ||||||||
| City: | NATCHEZ | ||||||||
| State: | MS | ||||||||
| PostalCode: | 391204792 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6014466068 | ||||||||
| FaxNumber: | 6014469990 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/15/2007 | ||||||||
| LastUpdateDate: | 04/20/2008 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | RUBENSTEIN | ||||||||
| AuthorizedOfficialFirstName: | FORREST | ||||||||
| AuthorizedOfficialMiddleName: | SCOT | ||||||||
| AuthorizedOfficialTitleorPosition: | SURGEON | ||||||||
| AuthorizedOfficialTelephone: | 6014466068 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | M.D.,F.A.C.S | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 19606 | MS | Y | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 1548281926 | 01 | NPI | OTHER |