Healthcare Provider Details

I. General information

NPI: 1891728382
Provider Name (Legal Business Name): MISSISSIPPI COAST ENDOSCOPY & AMBULATORY CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/08/2006
Last Update Date: 01/27/2023
Certification Date: 01/27/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2406 CATALPA AVE
PASCAGOULA MS
39567-1813
US

IV. Provider business mailing address

2406 CATALPA AVE
PASCAGOULA MS
39567-1813
US

V. Phone/Fax

Practice location:
  • Phone: 228-696-0818
  • Fax: 228-696-0893
Mailing address:
  • Phone:
  • Fax: 228-696-0893

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number019
License Number StateMS

VIII. Authorized Official

Name: KATHERINE RENEE JUDKINS
Title or Position: VICE PRESIDENT
Credential:
Phone: 615-240-3770