Provider Demographics
NPI:1649685561
Name:MEMORIAL HOSPITAL @ GULFPORT
Entity type:Organization
Organization Name:MEMORIAL HOSPITAL @ GULFPORT
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:E
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:228-575-1970
Mailing Address - Street 1:11150 HIGHWAY 49
Mailing Address - Street 2:
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39503-4110
Mailing Address - Country:US
Mailing Address - Phone:228-575-1000
Mailing Address - Fax:228-575-2002
Practice Address - Street 1:11150 HIGHWAY 49
Practice Address - Street 2:
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39503-4110
Practice Address - Country:US
Practice Address - Phone:228-575-1000
Practice Address - Fax:228-575-2002
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-06-30
Last Update Date:2014-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSC68161041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty