Provider Demographics
NPI:1568585016
Name:BILOXI OB GYN CLINIC
Entity Type:Organization
Organization Name:BILOXI OB GYN CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:LATISHA
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:WISNIEWSKI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:228-702-1500
Mailing Address - Street 1:1720A MEDICAL PARK DR
Mailing Address - Street 2:SUITE 300
Mailing Address - City:BILOXI
Mailing Address - State:MS
Mailing Address - Zip Code:39532-2129
Mailing Address - Country:US
Mailing Address - Phone:228-702-1500
Mailing Address - Fax:228-702-1505
Practice Address - Street 1:1720A MEDICAL PARK DR
Practice Address - Street 2:SUTIE 300
Practice Address - City:BILOXI
Practice Address - State:MS
Practice Address - Zip Code:39532-2129
Practice Address - Country:US
Practice Address - Phone:228-702-1500
Practice Address - Fax:228-702-1505
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-09
Last Update Date:2008-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MSC00958Medicare PIN