Provider Demographics
NPI:1518071570
Name:LUCEDALE OB/GYN CENTER
Entity Type:Organization
Organization Name:LUCEDALE OB/GYN CENTER
Other - Org Name:OBSTETRICS & GYNECOLOGY ASSOCIATES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:AO
Authorized Official - Prefix:MS
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:
Authorized Official - Last Name:RUTLEDGE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-947-1330
Mailing Address - Street 1:PO BOX 1007
Mailing Address - Street 2:
Mailing Address - City:LUCEDALE
Mailing Address - State:MS
Mailing Address - Zip Code:39452-1007
Mailing Address - Country:US
Mailing Address - Phone:601-947-6000
Mailing Address - Fax:601-947-9436
Practice Address - Street 1:859 WINTER ST STE A
Practice Address - Street 2:
Practice Address - City:LUCEDALE
Practice Address - State:MS
Practice Address - Zip Code:39452-6603
Practice Address - Country:US
Practice Address - Phone:601-947-6000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-18
Last Update Date:2020-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MSC02852OtherMEDICARE PART B
MS09014803Medicaid
MSC02852OtherMEDICARE PART B