Provider Demographics
NPI:1962464438
Name:BILOXI INTERNAL MEDICINE CLINIC PA
Entity Type:Organization
Organization Name:BILOXI INTERNAL MEDICINE CLINIC PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARION
Authorized Official - Middle Name:JEAN
Authorized Official - Last Name:WAINWRIGHT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:228-374-2051
Mailing Address - Street 1:147 REYNOIR STREET
Mailing Address - Street 2:SUITE 204
Mailing Address - City:BILOXI
Mailing Address - State:MS
Mailing Address - Zip Code:39530
Mailing Address - Country:US
Mailing Address - Phone:228-374-2051
Mailing Address - Fax:228-374-5741
Practice Address - Street 1:147 REYNOIR STREET
Practice Address - Street 2:SUITE 204
Practice Address - City:BILOXI
Practice Address - State:MS
Practice Address - Zip Code:39530
Practice Address - Country:US
Practice Address - Phone:228-374-2051
Practice Address - Fax:228-374-5741
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-03
Last Update Date:2008-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09012028Medicaid
0285Medicare ID - Type Unspecified