Healthcare Provider Details

I. General information

NPI: 1639429970
Provider Name (Legal Business Name): MISISSIPPI PROVIDENCE HEALTHCARE SERVICES, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/13/2012
Last Update Date: 01/22/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5907 HIGHWAY 90
MOSS POINT MS
39563-6536
US

IV. Provider business mailing address

PO BOX 850489
MOBILE AL
36685-0489
US

V. Phone/Fax

Practice location:
  • Phone: 228-769-2611
  • Fax: 228-762-1638
Mailing address:
  • Phone: 251-342-3949
  • Fax: 251-631-3361

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number StateAL

VIII. Authorized Official

Name: MR. CLARK P. CHRISTIANSON
Title or Position: PRESIDENT
Credential:
Phone: 251-631-3574