Provider Demographics
NPI:1295928893
Name:ORANGE GROVE MEDICAL SPECIALTIES, P.A.
Entity type:Organization
Organization Name:ORANGE GROVE MEDICAL SPECIALTIES, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:LISA
Authorized Official - Middle Name:
Authorized Official - Last Name:LEATHERWOOD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:228-832-5151
Mailing Address - Street 1:15286 COMMUNITY RD
Mailing Address - Street 2:
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39503
Mailing Address - Country:US
Mailing Address - Phone:228-832-5151
Mailing Address - Fax:228-832-6320
Practice Address - Street 1:15286 COMMUNITY RD
Practice Address - Street 2:
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39503-3509
Practice Address - Country:US
Practice Address - Phone:228-832-5151
Practice Address - Fax:228-832-6320
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-27
Last Update Date:2015-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MSCL2948OtherRAILROAD MEDICARE
MSCO2049Medicare PIN