1285660688 NPI number — GARDEN PARK PHYSICIAN GROUP INC

Table of content: (NPI 1285660688)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1285660688 NPI number — GARDEN PARK PHYSICIAN GROUP INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GARDEN PARK PHYSICIAN GROUP INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1285660688
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/15/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3 MARYLAND FARMS
Provider Second Line Business Mailing Address:
SUITE 250
Provider Business Mailing Address City Name:
BRENTWOOD
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37027-5005
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
615-373-7600
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
416 E PASS RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GULFPORT
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
39507-3236
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
228-896-6505
Provider Business Practice Location Address Fax Number:
228-896-6509
Provider Enumeration Date:
06/25/2006

Additional Information

Authorized Official

Authorized Official Last Name:
JOSEPH
Authorized Official First Name:
LOUIS
Authorized Official Middle Name:
R.
Authorized Official Title or Position:
VP
Authorized Official Telephone Number:
615-373-7600

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 208000000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 367A00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 09016021 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1285660688 , issued by the state of ( AL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 01622395 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".
  • Identifier: 05826810 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".
  • Identifier: 08838517 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".
  • Identifier: 09016020 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".
  • Identifier: 09106019 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".




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