Provider Demographics
NPI:1912121120
Name:SOUTHWEST MISSISSIPPI REGIONAL MEDICAL CENTER
Entity Type:Organization
Organization Name:SOUTHWEST MISSISSIPPI REGIONAL MEDICAL CENTER
Other - Org Name:S M R M C INPATIENT REHAB
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:NORMAN
Authorized Official - Middle Name:
Authorized Official - Last Name:PRICE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-249-5500
Mailing Address - Street 1:PO BOX 1307
Mailing Address - Street 2:
Mailing Address - City:MCCOMB
Mailing Address - State:MS
Mailing Address - Zip Code:39649-1307
Mailing Address - Country:US
Mailing Address - Phone:601-249-5500
Mailing Address - Fax:601-249-1709
Practice Address - Street 1:215 MARION AVE
Practice Address - Street 2:
Practice Address - City:MCCOMB
Practice Address - State:MS
Practice Address - Zip Code:39648-2705
Practice Address - Country:US
Practice Address - Phone:601-249-5500
Practice Address - Fax:601-249-1709
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-12
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS11-251273Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes273Y00000XHospital UnitsRehabilitation Unit
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00020207Medicaid
MS=========OtherCOMMERCIAL TAX ID NUMBER
MS=========012OtherCHAMPUSTRICARE
MS00020207Medicaid