Healthcare Provider Details

I. General information

NPI: 1114353539
Provider Name (Legal Business Name): SOUTH CENTRAL REGIONAL MEDICAL CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/17/2013
Last Update Date: 09/17/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

920 MATTHEW DR SUITE 8
WAYNESBORO MS
39367-2553
US

IV. Provider business mailing address

PO BOX 1649
LAUREL MS
39441-1649
US

V. Phone/Fax

Practice location:
  • Phone: 601-425-7583
  • Fax: 601-399-6281
Mailing address:
  • Phone: 601-425-7583
  • Fax: 601-399-6281

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number
License Number State

VIII. Authorized Official

Name: JAMES T CANIZARO
Title or Position: VP OF FINANCE/CFO
Credential:
Phone: 601-399-6139