Healthcare Provider Details

I. General information

NPI: 1295820249
Provider Name (Legal Business Name): NEW CEDAR LAKE SURGERY CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/04/2006
Last Update Date: 02/20/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1720 MEDICAL PARK DR # B
BILOXI MS
39532-2131
US

IV. Provider business mailing address

1720 MEDICAL PARK DR # B
BILOXI MS
39532-2131
US

V. Phone/Fax

Practice location:
  • Phone: 228-702-2000
  • Fax: 228-702-2019
Mailing address:
  • Phone: 228-702-2000
  • Fax: 228-314-2589

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number004
License Number StateMS

VIII. Authorized Official

Name: MR. CHARLES J WILSON
Title or Position: OWNER AND DIRECTOR
Credential: M.D.
Phone: 228-702-2000