Provider Demographics
NPI:1265451231
Name:MEDICAL FOUNDATION OF SOUTH MS
Entity Type:Organization
Organization Name:MEDICAL FOUNDATION OF SOUTH MS
Other - Org Name:CHILDREN'S CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:RANDY
Authorized Official - Middle Name:
Authorized Official - Last Name:ROBINSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:228-865-1453
Mailing Address - Street 1:1612 31ST AVE
Mailing Address - Street 2:
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39501-2750
Mailing Address - Country:US
Mailing Address - Phone:228-865-1453
Mailing Address - Fax:228-865-1451
Practice Address - Street 1:20091 PINEVILLE RD
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:MS
Practice Address - Zip Code:39560-3208
Practice Address - Country:US
Practice Address - Phone:228-868-3684
Practice Address - Fax:228-868-3795
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-19
Last Update Date:2008-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09014471Medicaid
MS09014471Medicaid