Provider Demographics
NPI:1780774745
Name:EAST MISSISSIPPI ENDOSCOPY CENTER LLC
Entity type:Organization
Organization Name:EAST MISSISSIPPI ENDOSCOPY CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CENTER DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:CRYSTAL
Authorized Official - Middle Name:
Authorized Official - Last Name:BOLER
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:601-485-1131
Mailing Address - Street 1:1926 23RD AVE
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:MS
Mailing Address - Zip Code:39301-3107
Mailing Address - Country:US
Mailing Address - Phone:601-485-1131
Mailing Address - Fax:601-485-1336
Practice Address - Street 1:1926 23RD AVE
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:MS
Practice Address - Zip Code:39301-3107
Practice Address - Country:US
Practice Address - Phone:601-485-1131
Practice Address - Fax:601-485-1336
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-13
Last Update Date:2010-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS490003787OtherMEDICARE RAILROAD ID
MS000050792OtherSTATE MS PROVIDER ID
MS00770276Medicaid
MS00770276Medicaid
MS00770276Medicaid