Healthcare Provider Details

I. General information

NPI: 1942754338
Provider Name (Legal Business Name): SOUTHERN DIGESTIVE HEALTH CENTER,LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/15/2016
Last Update Date: 06/11/2021
Certification Date: 06/11/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 HOSPITAL DR
TYLERTOWN MS
39667-2021
US

IV. Provider business mailing address

101 HOSPITAL DR
TYLERTOWN MS
39667-2021
US

V. Phone/Fax

Practice location:
  • Phone: 601-827-5075
  • Fax: 601-827-5133
Mailing address:
  • Phone: 601-827-5075
  • Fax: 601-827-5733

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberAD9666895
License Number StateMS
# 2
Primary TaxonomyN
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MRS. LINDA U ANAZIA
Title or Position: ADMINISTRATOR
Credential:
Phone: 601-249-0013