Provider Demographics
NPI:1063663490
Name:MEMORIAL HOSPITAL AT GULFPORT
Entity Type:Organization
Organization Name:MEMORIAL HOSPITAL AT GULFPORT
Other - Org Name:PHYSICIANS CLINIC AT MHG
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VP OF FINANCE
Authorized Official - Prefix:MR
Authorized Official - First Name:JEFF
Authorized Official - Middle Name:T
Authorized Official - Last Name:STEINER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:228-865-3106
Mailing Address - Street 1:PO BOX 555
Mailing Address - Street 2:
Mailing Address - City:BILOXI
Mailing Address - State:MS
Mailing Address - Zip Code:39533-0555
Mailing Address - Country:US
Mailing Address - Phone:228-864-1453
Mailing Address - Fax:
Practice Address - Street 1:1340 BROAD AVE
Practice Address - Street 2:SUITE 140
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39501-2404
Practice Address - Country:US
Practice Address - Phone:228-818-0563
Practice Address - Fax:228-818-0519
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-03
Last Update Date:2011-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation OncologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS05576036Medicaid
MS512G700454Medicare UPIN