Healthcare Provider Details

I. General information

NPI: 1265451231
Provider Name (Legal Business Name): MEDICAL FOUNDATION OF SOUTH MS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/19/2006
Last Update Date: 05/23/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20091 PINEVILLE RD
LONG BEACH MS
39560-3208
US

IV. Provider business mailing address

1612 31ST AVE
GULFPORT MS
39501-2750
US

V. Phone/Fax

Practice location:
  • Phone: 228-868-3684
  • Fax: 228-868-3795
Mailing address:
  • Phone: 228-865-1453
  • Fax: 228-865-1451

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. RANDY ROBINSON
Title or Position: ADMINISTRATOR
Credential:
Phone: 228-865-1453