Provider Demographics
NPI:1295922854
Name:GARDEN PARK HOSPITALIST PROGRAM LLC
Entity type:Organization
Organization Name:GARDEN PARK HOSPITALIST PROGRAM LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:M
Authorized Official - Last Name:LAVERTY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-507-2312
Mailing Address - Street 1:15200 COMMUNITY RD
Mailing Address - Street 2:4TH FLOOR
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39503-3085
Mailing Address - Country:US
Mailing Address - Phone:228-575-7243
Mailing Address - Fax:801-575-7420
Practice Address - Street 1:15200 COMMUNITY RD
Practice Address - Street 2:4TH FLOOR
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39503-3085
Practice Address - Country:US
Practice Address - Phone:228-575-7243
Practice Address - Fax:801-575-7420
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-27
Last Update Date:2009-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS07378761Medicaid
DO4436Medicare PIN
MS512G700025Medicare PIN