Provider Demographics
NPI:1942392386
Name:GARDEN PARK PHYSICIAN SERVICES CORP.
Entity Type:Organization
Organization Name:GARDEN PARK PHYSICIAN SERVICES CORP.
Other - Org Name:FAMILY HEALTH CARE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:LEGESSE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-373-7630
Mailing Address - Street 1:15190 COMMUNITY RD
Mailing Address - Street 2:SUITE 330
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39503-3485
Mailing Address - Country:US
Mailing Address - Phone:228-832-3075
Mailing Address - Fax:228-832-9095
Practice Address - Street 1:15190 COMMUNITY RD
Practice Address - Street 2:SUITE 330
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39503-3485
Practice Address - Country:US
Practice Address - Phone:228-832-3075
Practice Address - Fax:228-832-9095
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-29
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes176B00000XOther Service ProvidersMidwifeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS08838517Medicaid
MS08838517Medicaid
MS08838517Medicaid