Provider Demographics
NPI:1114353539
Name:SOUTH CENTRAL REGIONAL MEDICAL CENTER
Entity Type:Organization
Organization Name:SOUTH CENTRAL REGIONAL MEDICAL CENTER
Other - Org Name:SOUTH CENTRAL DERMATOLOGY CLINIC - WAYNESBORO
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VP OF FINANCE/CFO
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:T
Authorized Official - Last Name:CANIZARO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-399-6139
Mailing Address - Street 1:PO BOX 1649
Mailing Address - Street 2:
Mailing Address - City:LAUREL
Mailing Address - State:MS
Mailing Address - Zip Code:39441-1649
Mailing Address - Country:US
Mailing Address - Phone:601-425-7583
Mailing Address - Fax:601-399-6281
Practice Address - Street 1:920 MATTHEW DR
Practice Address - Street 2:SUITE 8
Practice Address - City:WAYNESBORO
Practice Address - State:MS
Practice Address - Zip Code:39367-2553
Practice Address - Country:US
Practice Address - Phone:601-425-7583
Practice Address - Fax:601-399-6281
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-09-17
Last Update Date:2013-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty