Provider Demographics
NPI:1043690936
Name:GEORGE REGIONAL ER PHYSICIANS
Entity Type:Organization
Organization Name:GEORGE REGIONAL ER PHYSICIANS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:KATHY
Authorized Official - Middle Name:
Authorized Official - Last Name:FENDER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-947-8181
Mailing Address - Street 1:PO BOX 1007
Mailing Address - Street 2:
Mailing Address - City:LUCEDALE
Mailing Address - State:MS
Mailing Address - Zip Code:39452-1007
Mailing Address - Country:US
Mailing Address - Phone:601-947-1332
Mailing Address - Fax:601-947-1331
Practice Address - Street 1:859 WINTER ST
Practice Address - Street 2:
Practice Address - City:LUCEDALE
Practice Address - State:MS
Practice Address - Zip Code:39452-6603
Practice Address - Country:US
Practice Address - Phone:601-947-3161
Practice Address - Fax:601-947-1331
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-06-04
Last Update Date:2016-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical ServicesGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS01839854Medicaid
MS423780Medicare PIN