Provider Demographics
NPI:1265478077
Name:SOUTH MISSISSIPPI EMERGENCY PHYSICIANS PA
Entity Type:Organization
Organization Name:SOUTH MISSISSIPPI EMERGENCY PHYSICIANS PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:NELSON
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:601-288-7000
Mailing Address - Street 1:PO BOX 635614
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45263-5614
Mailing Address - Country:US
Mailing Address - Phone:601-288-2010
Mailing Address - Fax:601-288-2193
Practice Address - Street 1:6051 HIGHWAY 49
Practice Address - Street 2:
Practice Address - City:HATTIESBURG
Practice Address - State:MS
Practice Address - Zip Code:39401-7200
Practice Address - Country:US
Practice Address - Phone:601-288-2010
Practice Address - Fax:601-288-2193
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-21
Last Update Date:2008-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09016106Medicaid
MSCK4284OtherRRGA
MS09016106Medicaid