Provider Demographics
NPI:1215035498
Name:SOUTH MISSISSIPPI DURABLE MEDICAL
Entity Type:Organization
Organization Name:SOUTH MISSISSIPPI DURABLE MEDICAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:MR
Authorized Official - First Name:CLARENCE
Authorized Official - Middle Name:A
Authorized Official - Last Name:HAMILTON
Authorized Official - Suffix:III
Authorized Official - Credentials:
Authorized Official - Phone:504-813-9037
Mailing Address - Street 1:1821 OLD SPANISH TRL
Mailing Address - Street 2:SUITE A
Mailing Address - City:GAUTIER
Mailing Address - State:MS
Mailing Address - Zip Code:39553-6069
Mailing Address - Country:US
Mailing Address - Phone:228-497-9590
Mailing Address - Fax:
Practice Address - Street 1:1821 OLD SPANISH TRL
Practice Address - Street 2:SUITE A
Practice Address - City:GAUTIER
Practice Address - State:MS
Practice Address - Zip Code:39553-6069
Practice Address - Country:US
Practice Address - Phone:228-497-9590
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-20
Last Update Date:2008-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS5863490001Medicare NSC