Provider Demographics
NPI:1417005067
Name:SOUTH CENTRAL REGIONAL MEDICAL CENTER
Entity Type:Organization
Organization Name:SOUTH CENTRAL REGIONAL MEDICAL CENTER
Other - Org Name:SOUTH CENTRAL REG MED CTR -RAILROAD EKG
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:T
Authorized Official - Last Name:CANIZARO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-426-4504
Mailing Address - Street 1:PO BOX 607
Mailing Address - Street 2:
Mailing Address - City:LAUREL
Mailing Address - State:MS
Mailing Address - Zip Code:39441-0607
Mailing Address - Country:US
Mailing Address - Phone:601-426-4000
Mailing Address - Fax:601-399-6254
Practice Address - Street 1:1220 JEFFERSON ST
Practice Address - Street 2:
Practice Address - City:LAUREL
Practice Address - State:MS
Practice Address - Zip Code:39440-4355
Practice Address - Country:US
Practice Address - Phone:601-426-4000
Practice Address - Fax:601-399-6254
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SOUTH CENTRAL REGIONAL MEDICAL CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-01-08
Last Update Date:2010-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS11-153207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS0000019141OtherBLUE CROSS
MSCJ0773OtherMEDICARE PTAN