1639429970 NPI number — MISISSIPPI PROVIDENCE HEALTHCARE SERVICES, INC.

Table of content: (NPI 1639429970)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1639429970 NPI number — MISISSIPPI PROVIDENCE HEALTHCARE SERVICES, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MISISSIPPI PROVIDENCE HEALTHCARE SERVICES, 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:
1639429970
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/22/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 850489
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MOBILE
Provider Business Mailing Address State Name:
AL
Provider Business Mailing Address Postal Code:
36685-0489
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
251-342-3949
Provider Business Mailing Address Fax Number:
251-631-3361

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5907 HIGHWAY 90
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MOSS POINT
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
39563-6536
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
228-769-2611
Provider Business Practice Location Address Fax Number:
228-762-1638
Provider Enumeration Date:
09/13/2012

Additional Information

Authorized Official

Authorized Official Last Name:
CHRISTIANSON
Authorized Official First Name:
CLARK
Authorized Official Middle Name:
P.
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
251-631-3574

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , registered in the state of AL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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