Healthcare Provider Details

I. General information

NPI: 1740617232
Provider Name (Legal Business Name): MEMORIAL HOSPITAL AT GULFPORT
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/30/2013
Last Update Date: 01/09/2024
Certification Date: 01/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1340 BROAD AVE STE 310
GULFPORT MS
39501-2464
US

IV. Provider business mailing address

PO BOX 1810
GULFPORT MS
39502-1810
US

V. Phone/Fax

Practice location:
  • Phone: 228-575-1400
  • Fax: 228-575-1414
Mailing address:
  • Phone: 228-575-1700
  • Fax: 228-575-1735

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207RI0200X
TaxonomyInfectious Disease Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: PEGGY LORRAINE NOONAN
Title or Position: PHYSICIAN BUSINESS SERVICES DIR.
Credential: BS, CPC
Phone: 228-575-1740