Healthcare Provider Details

I. General information

NPI: 1942554761
Provider Name (Legal Business Name): SOUTH CENTRAL REGIONAL MEDICAL CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/31/2012
Last Update Date: 10/31/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1203 AVENUE B
ELLISVILLE MS
39437-2080
US

IV. Provider business mailing address

1203 AVENUE B
ELLISVILLE MS
39437-2080
US

V. Phone/Fax

Practice location:
  • Phone: 601-477-8553
  • Fax: 601-477-9158
Mailing address:
  • Phone: 601-477-8553
  • Fax: 601-477-9158

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2080A0000X
TaxonomyPediatric Adolescent Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. JAMES T CANIZARO
Title or Position: C.F.O. / VICE PRESIDENT
Credential:
Phone: 601-399-6139