Healthcare Provider Details

I. General information

NPI: 1114923059
Provider Name (Legal Business Name): SOUTH CENTRAL REGIONAL MEDICAL CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/24/2005
Last Update Date: 11/16/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

305 E IVY ST
ELLISVILLE MS
39437-2746
US

IV. Provider business mailing address

PO BOX 607
LAUREL MS
39441-0607
US

V. Phone/Fax

Practice location:
  • Phone: 601-477-9381
  • Fax: 601-477-9870
Mailing address:
  • Phone: 601-399-6103
  • Fax: 601-399-6254

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number11153
License Number StateMS

VIII. Authorized Official

Name: JAMES T CANIZARO
Title or Position: CFO
Credential:
Phone: 601-426-4504