Provider Demographics
NPI:1346251477
Name:MISSISSIPPI COAST UROLOGY
Entity Type:Organization
Organization Name:MISSISSIPPI COAST UROLOGY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:DONALD
Authorized Official - Middle Name:S
Authorized Official - Last Name:DAVENPORT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:228-762-4483
Mailing Address - Street 1:2525 TELEPHONE RD
Mailing Address - Street 2:
Mailing Address - City:PASCAGOULA
Mailing Address - State:MS
Mailing Address - Zip Code:39567-3202
Mailing Address - Country:US
Mailing Address - Phone:228-762-4483
Mailing Address - Fax:228-769-0406
Practice Address - Street 1:2525 TELEPHONE RD
Practice Address - Street 2:
Practice Address - City:PASCAGOULA
Practice Address - State:MS
Practice Address - Zip Code:39567-3202
Practice Address - Country:US
Practice Address - Phone:228-762-4483
Practice Address - Fax:228-769-0406
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-11
Last Update Date:2011-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS13231208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MSC02910Medicare ID - Type Unspecified