Provider Demographics
NPI:1821342379
Name:SOUTH CENTRAL REGIONAL MEDICAL CENTER
Entity Type:Organization
Organization Name:SOUTH CENTRAL REGIONAL MEDICAL CENTER
Other - Org Name:LAUREL PEDIATRIC CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VICE PRESIDENT/ C.F.O.
Authorized Official - Prefix:MR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:T
Authorized Official - Last Name:CANIZARO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-399-6139
Mailing Address - Street 1:PO BOX 1649
Mailing Address - Street 2:
Mailing Address - City:LAUREL
Mailing Address - State:MS
Mailing Address - Zip Code:39441-1649
Mailing Address - Country:US
Mailing Address - Phone:601-425-7583
Mailing Address - Fax:601-399-6281
Practice Address - Street 1:234 S 12TH AVE
Practice Address - Street 2:
Practice Address - City:LAUREL
Practice Address - State:MS
Practice Address - Zip Code:39440-4325
Practice Address - Country:US
Practice Address - Phone:601-649-3520
Practice Address - Fax:601-649-7899
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-11-06
Last Update Date:2012-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS08705378Medicaid