Provider Demographics
NPI:1457566192
Name:NORTH BEACH MEDICAL LLC
Entity type:Organization
Organization Name:NORTH BEACH MEDICAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:REPRESENTATIVE
Authorized Official - Prefix:MR
Authorized Official - First Name:JACK
Authorized Official - Middle Name:J
Authorized Official - Last Name:HYMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:228-466-6373
Mailing Address - Street 1:P O BOX 2867
Mailing Address - Street 2:
Mailing Address - City:BAY ST LOUIS
Mailing Address - State:MS
Mailing Address - Zip Code:39521-2867
Mailing Address - Country:US
Mailing Address - Phone:228-466-6373
Mailing Address - Fax:228-466-6372
Practice Address - Street 1:523 ULMAN AVE
Practice Address - Street 2:
Practice Address - City:BAY ST LOUIS
Practice Address - State:MS
Practice Address - Zip Code:39520-3524
Practice Address - Country:US
Practice Address - Phone:228-466-6373
Practice Address - Fax:228-466-6372
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-14
Last Update Date:2011-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS=========AOtherBLUE CROSS BLUE SHIELD MS
MS5303830001Medicare NSC