Basic Information
| Provider Information | |||||||||
| NPI: | 1912038811 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | KING'S DAUGHTERS MEDICAL CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 427 HIGHWAY 51 N | ||||||||
| Address2: | |||||||||
| City: | BROOKHAVEN | ||||||||
| State: | MS | ||||||||
| PostalCode: | 396012350 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6018336011 | ||||||||
| FaxNumber: | 6018338742 | ||||||||
| Practice Location | |||||||||
| Address1: | 427 HIGHWAY 51 N | ||||||||
| Address2: | |||||||||
| City: | BROOKHAVEN | ||||||||
| State: | MS | ||||||||
| PostalCode: | 396012350 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6018336011 | ||||||||
| FaxNumber: | 6018338742 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/09/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | SNIDER | ||||||||
| AuthorizedOfficialFirstName: | GARY | ||||||||
| AuthorizedOfficialMiddleName: | DEAN | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF FINANCIAL OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 6012996011 | ||||||||
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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 | 282N00000X | 16235 | MS | Y | Hospitals | General Acute Care Hospital |
ID Information
| ID | Type | State | Issuer | Description | 09013547 | 05 | MS | MEDICAID |