Provider Demographics
NPI:1932122017
Name:MEMORIAL HOSPITAL AT GULFPORT
Entity Type:Organization
Organization Name:MEMORIAL HOSPITAL AT GULFPORT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:ZIEMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:228-575-1907
Mailing Address - Street 1:11150 HIGHWAY 49N
Mailing Address - Street 2:
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39503
Mailing Address - Country:US
Mailing Address - Phone:228-575-1000
Mailing Address - Fax:228-575-2002
Practice Address - Street 1:11150 HIGHWAY 49N
Practice Address - Street 2:
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39503
Practice Address - Country:US
Practice Address - Phone:228-575-1000
Practice Address - Fax:228-575-2002
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-26
Last Update Date:2015-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & BehavioralGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09015293Medicaid
MS512G700417Medicare UPIN
MS09015293Medicaid