Provider Demographics
NPI:1881882405
Name:GARDEN PARK PHYSICIAN SERVICES CORP
Entity type:Organization
Organization Name:GARDEN PARK PHYSICIAN SERVICES CORP
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:VP
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:LAGESSE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:866-653-0021
Mailing Address - Street 1:1924 30TH AVE
Mailing Address - Street 2:
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39501-4534
Mailing Address - Country:US
Mailing Address - Phone:228-832-2004
Mailing Address - Fax:228-832-4093
Practice Address - Street 1:1924 30TH AVE
Practice Address - Street 2:
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39501-4534
Practice Address - Country:US
Practice Address - Phone:228-832-2004
Practice Address - Fax:228-832-4093
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-09
Last Update Date:2007-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MSJ5628OtherRR MEDICARE
MS09016021Medicaid
MS09016021Medicaid