Provider Demographics
NPI:1073606901
Name:MEMORIAL HOSPITAL AT GULFPORT
Entity Type:Organization
Organization Name:MEMORIAL HOSPITAL AT GULFPORT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:KENT
Authorized Official - Middle Name:
Authorized Official - Last Name:NICAUD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:228-865-3076
Mailing Address - Street 1:PO BOX 1810
Mailing Address - Street 2:
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39502-1810
Mailing Address - Country:US
Mailing Address - Phone:228-867-3076
Mailing Address - Fax:228-865-3098
Practice Address - Street 1:4500 13TH ST
Practice Address - Street 2:
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39501-2515
Practice Address - Country:US
Practice Address - Phone:228-867-3076
Practice Address - Fax:228-865-3098
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-02
Last Update Date:2024-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282N00000XHospitalsGeneral Acute Care Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00020027Medicaid
GA000260081XMedicaid
LA1943061Medicaid
ALMEM0019NMedicaid
LA1731625Medicaid
FL901382200Medicaid
MSCA1177OtherRAILROAD MEDICARE
MS027OtherBLUE CROSS BLUE SHIELD MS
TN1887007Medicaid
TN0250019Medicaid
MS374535800OtherUS DEPT OF LABOR NUMBER
MSC00042OtherCAHABA PROVIDER NUMBER
MS000019027OtherBLUE CROSS
MS000019027OtherBLUE CROSS
TN1887007Medicaid
ALMEM0019NMedicaid