Provider Demographics
NPI:1619066248
Name:MEMORIAL HOSPITAL AT GULFPORT
Entity Type:Organization
Organization Name:MEMORIAL HOSPITAL AT GULFPORT
Other - Org Name:MEMORIAL WOODLAND VILLAGE NURSING CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHYSICIAN BUSINESS SERVICES DIR.
Authorized Official - Prefix:
Authorized Official - First Name:PEGGY
Authorized Official - Middle Name:LORRAINE
Authorized Official - Last Name:NOONAN
Authorized Official - Suffix:
Authorized Official - Credentials:BS, CPC
Authorized Official - Phone:228-575-1740
Mailing Address - Street 1:5427 GEX RD
Mailing Address - Street 2:
Mailing Address - City:DIAMONDHEAD
Mailing Address - State:MS
Mailing Address - Zip Code:39525-3208
Mailing Address - Country:US
Mailing Address - Phone:228-255-4832
Mailing Address - Fax:228-255-4833
Practice Address - Street 1:5427 GEX RD
Practice Address - Street 2:
Practice Address - City:DIAMONDHEAD
Practice Address - State:MS
Practice Address - Zip Code:39525-3208
Practice Address - Country:US
Practice Address - Phone:228-255-4832
Practice Address - Fax:228-255-4833
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MEMORIAL HOSPITAL AT GULFPORT
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-10-12
Last Update Date:2024-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS692314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00230023Medicaid
MS255163Medicare ID - Type Unspecified