Healthcare Provider Details

I. General information

NPI: 1427316041
Provider Name (Legal Business Name): JEREMIAH JOHN BALDWIN IDC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/02/2012
Last Update Date: 06/10/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5303 MARVIN SHIELDS BLVD
GULFPORT MS
39501-9013
US

IV. Provider business mailing address

117 YUCCA DR
LONG BEACH MS
39560-3904
US

V. Phone/Fax

Practice location:
  • Phone: 228-822-5790
  • Fax:
Mailing address:
  • Phone: 360-969-1720
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1710I1002X
TaxonomyIndependent Duty Corpsman
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: