Healthcare Provider Details

I. General information

NPI: 1811171648
Provider Name (Legal Business Name): SOUTH MISSISSIPPI NEPHROLOGY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/28/2007
Last Update Date: 12/28/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4405 E ALOHA DR STE I
DIAMONDHEAD MS
39525-3380
US

IV. Provider business mailing address

4300B W RAILROAD ST
GULFPORT MS
39501
US

V. Phone/Fax

Practice location:
  • Phone: 228-863-7393
  • Fax: 228-864-0546
Mailing address:
  • Phone: 228-863-7393
  • Fax: 228-864-0546

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. DOUGLAS C LANIER JR.
Title or Position: MANAGING MEMBER
Credential: M.D.
Phone: 228-863-7393