=====================================================
General NPI Number Information
=====================================================
NPI Number | 1679509293
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MEDICAL FOUNDATION OF SOUTH MS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/24/2006
-----------------------------------------------------
Last Update Date | 05/23/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 12100 HIGHWAY 49
-----------------------------------------------------
City | GULFPORT
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39503-3063
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 228-831-1988
-----------------------------------------------------
Fax | 228-831-1978
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1612 31ST AVE
-----------------------------------------------------
City | GULFPORT
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39501-2750
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 228-865-1453
-----------------------------------------------------
Fax | 228-865-1451
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATOR
-----------------------------------------------------
Name | MR. RANDY ROBINSON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 228-865-1453
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207K00000X
-----------------------------------------------------
Taxonomy Name | Allergy & Immunology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 208000000X
-----------------------------------------------------
Taxonomy Name | Pediatrics Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------