Healthcare Provider Details

I. General information

NPI: 1619066248
Provider Name (Legal Business Name): MEMORIAL HOSPITAL AT GULFPORT
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/12/2006
Last Update Date: 01/09/2024
Certification Date: 01/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5427 GEX RD
DIAMONDHEAD MS
39525-3208
US

IV. Provider business mailing address

5427 GEX RD
DIAMONDHEAD MS
39525-3208
US

V. Phone/Fax

Practice location:
  • Phone: 228-255-4832
  • Fax: 228-255-4833
Mailing address:
  • Phone: 228-255-4832
  • Fax: 228-255-4833

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number692
License Number StateMS

VIII. Authorized Official

Name: PEGGY LORRAINE NOONAN
Title or Position: PHYSICIAN BUSINESS SERVICES DIR.
Credential: BS, CPC
Phone: 228-575-1740