Provider Demographics
NPI:1821233917
Name:MEDICAL FOUNDATION OF SOUTH MS
Entity Type:Organization
Organization Name:MEDICAL FOUNDATION OF SOUTH MS
Other - Org Name:SOUTHERN COAST FAMILY MEDICAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:RANDY
Authorized Official - Middle Name:
Authorized Official - Last Name:ROBINSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:228-865-1453
Mailing Address - Street 1:1612 31ST AVE
Mailing Address - Street 2:
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39501-2750
Mailing Address - Country:US
Mailing Address - Phone:228-865-1453
Mailing Address - Fax:228-865-1457
Practice Address - Street 1:394 COURTHOUSE RD
Practice Address - Street 2:SUITE A
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39507-1865
Practice Address - Country:US
Practice Address - Phone:228-896-4417
Practice Address - Fax:228-865-1457
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-12-04
Last Update Date:2008-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09014940Medicaid
MSC02001Medicare PIN