Provider Demographics
NPI:1356469423
Name:MEDICAL FOUNDATION OF SOUTH MS
Entity Type:Organization
Organization Name:MEDICAL FOUNDATION OF SOUTH MS
Other - Org Name:MEDICAL FOUNDATION OF SOUTH MS LAB
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 1:1110 BROAD AVE
Practice Address - Street 2:SUITE 700
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39501-8907
Practice Address - Country:US
Practice Address - Phone:228-864-4151
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-27
Last Update Date:2008-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
208000000X
MS291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes291U00000XLaboratoriesClinical Medical Laboratory
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00119065Medicaid
MSB64784Medicare UPIN
MSD00919Medicare UPIN
MSG58291Medicare UPIN
MSE58324Medicare UPIN
MSG70773Medicare UPIN
MSG57769Medicare UPIN
MSG78591Medicare UPIN
MSE86656Medicare UPIN
MSH34286Medicare UPIN
MSG82704Medicare UPIN
MS690000036Medicare PIN
MSB06702Medicare UPIN
MSG22699Medicare UPIN
MSG46494Medicare UPIN
MS690007566Medicare PIN
MSH73154Medicare UPIN
MSF88710Medicare UPIN
MSP81335Medicare UPIN
MS00119065Medicaid