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General NPI Number Information
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NPI Number | 1154360501
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Entity Type | Organization
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Legal Business Name | GULF SOUTH SURGERY CENTER LLC
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Dates
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Enumeration Date | 06/04/2006
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 1206 31ST AVE
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City | GULFPORT
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State | MS
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Zip | 39501-1804
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Country | US
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Telephone | 228-864-0008
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Fax |
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Provider Business Mailing Address
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Address Line | 1206 31ST AVE
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City | GULFPORT
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State | MS
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Zip | 39501-1804
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Country | US
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Telephone | 228-864-0008
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Fax |
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Authorized Official
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Title or Position | ADMINISTRATOR
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Name | DR. JASON SMITH
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Credential | MD
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Telephone | 228-818-0563
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QA1903X
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Taxonomy Name | Ambulatory Surgical Clinic/Center
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License Number | 002
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License Number State | MS
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