Provider Demographics
NPI:1952743049
Name:FMS GULFPORT, LLC
Entity Type:Organization
Organization Name:FMS GULFPORT, LLC
Other - Org Name:SOUTH MISSISSIPPI HOME
Other - Org Type:Doing Business As
Authorized Official - Title/Position:REGULATORY AFFAIRS SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:R
Authorized Official - Last Name:FAWCETT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:781-699-9303
Mailing Address - Street 1:3301 25TH AVE
Mailing Address - Street 2:
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39501-5910
Mailing Address - Country:US
Mailing Address - Phone:228-436-9819
Mailing Address - Fax:228-432-1744
Practice Address - Street 1:3301 25TH AVE
Practice Address - Street 2:
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39501-5910
Practice Address - Country:US
Practice Address - Phone:228-436-9819
Practice Address - Fax:228-432-1744
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FRESENIUS MEDICAL CARE HOLDINGS, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-07-18
Last Update Date:2013-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS261QE0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0700XAmbulatory Health Care FacilitiesClinic/CenterEnd-Stage Renal Disease (ESRD) Treatment