Provider Demographics
NPI:1528004322
Name:INTERNAL MEDICINE CLINIC OF PICAYUNE
Entity Type:Organization
Organization Name:INTERNAL MEDICINE CLINIC OF PICAYUNE
Other - Org Name:THE CENTER FOR HEALTH MANAGEMENT
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MD
Authorized Official - Prefix:DR
Authorized Official - First Name:STANFORD
Authorized Official - Middle Name:
Authorized Official - Last Name:OWEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:228-864-9669
Mailing Address - Street 1:3300 15TH ST
Mailing Address - Street 2:
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39501-3901
Mailing Address - Country:US
Mailing Address - Phone:228-864-9669
Mailing Address - Fax:228-864-9774
Practice Address - Street 1:3300 15TH ST
Practice Address - Street 2:
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39501-3901
Practice Address - Country:US
Practice Address - Phone:228-864-9669
Practice Address - Fax:228-864-9774
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-21
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS08597207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS05324518Medicaid
MSC03126Medicare ID - Type UnspecifiedMS MEDICARE GROUP NUMBER