Provider Demographics
NPI:1093031494
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 FINANCES
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:228-865-3469
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:228-864-0854
Mailing Address - Fax:228-865-1457
Practice Address - Street 1:15190 COMMUNITY RD
Practice Address - Street 2:SUITE 240
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39503-3485
Practice Address - Country:US
Practice Address - Phone:228-539-2242
Practice Address - Fax:228-539-2712
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-04-12
Last Update Date:2011-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS006OtherTRICARE GROUP
MS06372030Medicaid
MS512G700480Medicare PIN