MEDICARE: MEDICAL FOUNDATION OF SOUTH MS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207R00000X	Internal Medicine Physician

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1891731287
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MEDICAL FOUNDATION OF SOUTH MS

Provider Business Mailing Address
First Line	:	2500 14TH ST FL 4
Second Line	:	P.O. BOX 98
City	:	GULFPORT
State	:	MS
Zip	:	39501-1962
Country	:	US
Telephone Number	:	228-865-1453
Fax Number	:	228-865-1451

Provider Business Practice Location Address
First Line	:	5120 BEATLINE RD
Second Line	:	SUITE A
City	:	LONG BEACH
State	:	MS
Zip	:	39560-3815
Country	:	US
Telephone Number	:	228-868-4287
Fax Number	:	228-868-4293

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	MR. RANDY ROBINSON
Credential	:
Telephone Number	:	228-865-1453

Provider Enumeration Date	:	06/22/2006
Last Update Date	:	04/02/2008

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Directions to “MEDICAL FOUNDATION OF SOUTH MS ” Practice Location

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