Provider Demographics
NPI:1285660688
Name:GARDEN PARK PHYSICIAN GROUP INC
Entity Type:Organization
Organization Name:GARDEN PARK PHYSICIAN GROUP INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP
Authorized Official - Prefix:MR
Authorized Official - First Name:LOUIS
Authorized Official - Middle Name:R
Authorized Official - Last Name:JOSEPH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-373-7600
Mailing Address - Street 1:3 MARYLAND FARMS
Mailing Address - Street 2:SUITE 250
Mailing Address - City:BRENTWOOD
Mailing Address - State:TN
Mailing Address - Zip Code:37027-5005
Mailing Address - Country:US
Mailing Address - Phone:615-373-7600
Mailing Address - Fax:
Practice Address - Street 1:416 E PASS RD
Practice Address - Street 2:
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39507-3236
Practice Address - Country:US
Practice Address - Phone:228-896-6505
Practice Address - Fax:228-896-6509
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-25
Last Update Date:2013-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice MidwifeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09016021Medicaid
AL1285660688Medicaid
MS01622395Medicaid
MS05826810Medicaid
MS08838517Medicaid
MS09016020Medicaid
MS09106019Medicaid
MS08838517Medicaid
MS01622395Medicaid
MS09016021Medicaid
CJ5360Medicare PIN