Basic Information
| Provider Information | |||||||||
| NPI: | 1932679958 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | OCEANS MISSISSIPPI MEDICAL GROUP LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3905 HEDGCOXE RD UNIT 250249 | ||||||||
| Address2: | |||||||||
| City: | PLANO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 750250840 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9724640022 | ||||||||
| FaxNumber: | 9724640021 | ||||||||
| Practice Location | |||||||||
| Address1: | 152 GATEWAY DR | ||||||||
| Address2: | |||||||||
| City: | BILOXI | ||||||||
| State: | MS | ||||||||
| PostalCode: | 395314409 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3374080797 | ||||||||
| FaxNumber: | 2283887259 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/03/2018 | ||||||||
| LastUpdateDate: | 01/05/2022 | ||||||||
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| AuthorizedOfficialLastName: | TARANTINO | ||||||||
| AuthorizedOfficialFirstName: | LAURA | ||||||||
| AuthorizedOfficialMiddleName: | F. | ||||||||
| AuthorizedOfficialTitleorPosition: | EVP, GENERAL COUNSEL | ||||||||
| AuthorizedOfficialTelephone: | 9724640022 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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| NPICertificationDate: | 01/05/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0805X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Geriatric Psychiatry |
No ID Information.