Healthcare Provider Details

I. General information

NPI: 1417040213
Provider Name (Legal Business Name): JOSEPH P. SHRUM MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/02/2006
Last Update Date: 02/05/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1245 42ND AVE
GULFPORT MS
39501-2666
US

IV. Provider business mailing address

1245 42ND AVE
GULFPORT MS
39501-2666
US

V. Phone/Fax

Practice location:
  • Phone: 228-864-8049
  • Fax: 228-864-7655
Mailing address:
  • Phone: 228-864-8049
  • Fax: 228-864-7655

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number11871
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: