Basic Information
| Provider Information | |||||||||
| NPI: | 1932721222 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SOUTHWEST MISSISSIPPI REGIONAL MEDICAL CENTER | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | GASTROENTEROLOGY ASSOCIATES-MONTICELLO | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 490 | ||||||||
| Address2: | |||||||||
| City: | MCCOMB | ||||||||
| State: | MS | ||||||||
| PostalCode: | 396490490 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6012492701 | ||||||||
| FaxNumber: | 6012492195 | ||||||||
| Practice Location | |||||||||
| Address1: | 1065 E BROAD ST | ||||||||
| Address2: | |||||||||
| City: | MONTICELLO | ||||||||
| State: | MS | ||||||||
| PostalCode: | 396547703 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6012494710 | ||||||||
| FaxNumber: | 6012494716 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/11/2020 | ||||||||
| LastUpdateDate: | 11/06/2020 | ||||||||
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| AuthorizedOfficialLastName: | ROWLEY | ||||||||
| AuthorizedOfficialFirstName: | CHARLA | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 6012491806 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | SOUTHWEST MISSISSIPPI REGIONAL MEDICAL CENTER | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 11/06/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RG0100X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology |
ID Information
| ID | Type | State | Issuer | Description | 08520320 | 05 | MS | MEDICAID |