Basic Information
| Provider Information | |||||||||
| NPI: | 1932213840 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SOUTH CENTRAL REGIONAL MEDICAL CENTER | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | SOUTH CENTRAL REGIONAL MEDICAL CENTER- A&D | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 607 | ||||||||
| Address2: | |||||||||
| City: | LAUREL | ||||||||
| State: | MS | ||||||||
| PostalCode: | 394410607 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6013996103 | ||||||||
| FaxNumber: | 6013996254 | ||||||||
| Practice Location | |||||||||
| Address1: | 1220 JEFFERSON ST | ||||||||
| Address2: | |||||||||
| City: | LAUREL | ||||||||
| State: | MS | ||||||||
| PostalCode: | 394404355 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6014264000 | ||||||||
| FaxNumber: | 6014264228 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/18/2006 | ||||||||
| LastUpdateDate: | 04/23/2008 | ||||||||
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| AuthorizedOfficialLastName: | CANIZARO | ||||||||
| AuthorizedOfficialFirstName: | JAMES | ||||||||
| AuthorizedOfficialMiddleName: | T | ||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 6014264504 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 276400000X | 11153 | MS | Y | Hospital Units | Rehabilitation, Substance Use Disorder Unit |
ID Information
| ID | Type | State | Issuer | Description | 000020141 | 01 | MS | BLUE CROSS | OTHER |