Healthcare Provider Details

I. General information

NPI: 1518071570
Provider Name (Legal Business Name): LUCEDALE OB/GYN CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/18/2006
Last Update Date: 02/04/2020
Certification Date: 02/04/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

859 WINTER ST STE A
LUCEDALE MS
39452-6603
US

IV. Provider business mailing address

PO BOX 1007
LUCEDALE MS
39452-1007
US

V. Phone/Fax

Practice location:
  • Phone: 601-947-6000
  • Fax:
Mailing address:
  • Phone: 601-947-6000
  • Fax: 601-947-9436

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QR1300X
TaxonomyRural Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MS. SUSAN RUTLEDGE
Title or Position: AO
Credential:
Phone: 601-947-1330