=====================================================
General NPI Number Information
=====================================================
NPI Number | 1366003105
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | REBECCA ANNE WALDRUP DO
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/24/2019
-----------------------------------------------------
Last Update Date | 07/08/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | KEESLER AIR FORCE BASE MEDICAL CENTER 101 FISHER ST
-----------------------------------------------------
City | BILOXI
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39534
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 228-376-0500
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3919 HANSHAW RD
-----------------------------------------------------
City | OCEAN SPRINGS
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39564-9458
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 319-784-8079
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207P00000X
-----------------------------------------------------
Taxonomy Name | Emergency Medicine Physician
-----------------------------------------------------
License Number | 34.015002
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 390200000X
-----------------------------------------------------
Taxonomy Name | Student in an Organized Health Care Education/Training Program
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 207PE0004X
-----------------------------------------------------
Taxonomy Name | Emergency Medical Services (Emergency Medicine) Physician
-----------------------------------------------------
License Number | 32648
-----------------------------------------------------
License Number State | MS
-----------------------------------------------------