Provider Demographics
NPI:1417900465
Name:CANON HOSPICE-MISSISSIPPI INC
Entity Type:Organization
Organization Name:CANON HOSPICE-MISSISSIPPI INC
Other - Org Name:CANON HOSPICE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SHIVA
Authorized Official - Middle Name:K
Authorized Official - Last Name:AKULA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:504-669-3825
Mailing Address - Street 1:PO BOX 850715
Mailing Address - Street 2:
Mailing Address - City:NEW ORLEANS
Mailing Address - State:LA
Mailing Address - Zip Code:70185-0715
Mailing Address - Country:US
Mailing Address - Phone:504-669-3825
Mailing Address - Fax:228-575-8225
Practice Address - Street 1:1520 BROAD AVE
Practice Address - Street 2:SUITE 500
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39501-3601
Practice Address - Country:US
Practice Address - Phone:228-575-6251
Practice Address - Fax:228-575-8225
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-19
Last Update Date:2014-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS135251G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251G00000XAgenciesHospice Care, Community Based
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS251627Medicare Oscar/Certification