Healthcare Provider Details

I. General information

NPI: 1639155088
Provider Name (Legal Business Name): THE MEDICAL ONCOLOGY GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/19/2005
Last Update Date: 09/16/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1340 BROAD AVE SUITE 270
GULFPORT MS
39501-2404
US

IV. Provider business mailing address

PO BOX 1210
GULFPORT MS
39502-1210
US

V. Phone/Fax

Practice location:
  • Phone: 228-575-1234
  • Fax: 228-575-1240
Mailing address:
  • Phone: 228-575-1234
  • Fax: 228-575-1240

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State

VIII. Authorized Official

Name: EDWIN M DAVIDSON
Title or Position: SENIOR PARTNER/PHYSICIAN
Credential: MD
Phone: 228-575-1234