Provider Demographics
NPI:1114923059
Name:SOUTH CENTRAL REGIONAL MEDICAL CENTER
Entity Type:Organization
Organization Name:SOUTH CENTRAL REGIONAL MEDICAL CENTER
Other - Org Name:SOUTH CENTRAL EXTENDED CARE FACILITY
Other - Org Type:Doing Business As
Authorized Official - Title/Position: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:601-426-4504
Mailing Address - Street 1:PO BOX 607
Mailing Address - Street 2:
Mailing Address - City:LAUREL
Mailing Address - State:MS
Mailing Address - Zip Code:39441-0607
Mailing Address - Country:US
Mailing Address - Phone:601-399-6103
Mailing Address - Fax:601-399-6254
Practice Address - Street 1:305 E IVY ST
Practice Address - Street 2:
Practice Address - City:ELLISVILLE
Practice Address - State:MS
Practice Address - Zip Code:39437-2746
Practice Address - Country:US
Practice Address - Phone:601-477-9381
Practice Address - Fax:601-477-9870
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-24
Last Update Date:2007-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS11153314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS255189Medicare ID - Type Unspecified
CJ0773Medicare ID - Type UnspecifiedMEDICARE PART B RAILROAD
MSC00164Medicare ID - Type UnspecifiedMEDICARE PART B