Healthcare Provider Details

I. General information

NPI: 1679831531
Provider Name (Legal Business Name): SCOTT REGIONAL MEDICAL CENTER, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/30/2012
Last Update Date: 04/21/2023
Certification Date: 04/21/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1080 HIGHWAY 35 S
FOREST MS
39074-9423
US

IV. Provider business mailing address

DEPT 3029 PO BOX 1000
MEMPHIS TN
38148-3029
US

V. Phone/Fax

Practice location:
  • Phone: 601-469-3555
  • Fax: 601-469-3584
Mailing address:
  • Phone: 601-213-3010
  • Fax: 601-213-3011

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code261QR1300X
TaxonomyRural Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DON LARKIN KENNEDY
Title or Position: REGIONAL CEO
Credential:
Phone: 601-703-9614