Basic Information
| Provider Information | |||||||||
| NPI: | 1285660688 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | GARDEN PARK PHYSICIAN GROUP INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3 MARYLAND FARMS | ||||||||
| Address2: | SUITE 250 | ||||||||
| City: | BRENTWOOD | ||||||||
| State: | TN | ||||||||
| PostalCode: | 370275005 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6153737600 | ||||||||
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| Practice Location | |||||||||
| Address1: | 416 E PASS RD | ||||||||
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| City: | GULFPORT | ||||||||
| State: | MS | ||||||||
| PostalCode: | 395073236 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2288966505 | ||||||||
| FaxNumber: | 2288966509 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/25/2006 | ||||||||
| LastUpdateDate: | 03/15/2013 | ||||||||
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| AuthorizedOfficialLastName: | JOSEPH | ||||||||
| AuthorizedOfficialFirstName: | LOUIS | ||||||||
| AuthorizedOfficialMiddleName: | R. | ||||||||
| AuthorizedOfficialTitleorPosition: | VP | ||||||||
| AuthorizedOfficialTelephone: | 6153737600 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | 367A00000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Advanced Practice Midwife | 207R00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 09016021 | 05 | MS | MEDICAID | 1285660688 | 05 | AL | MEDICAID | 01622395 | 05 | MS | MEDICAID | 05826810 | 05 | MS | MEDICAID | 08838517 | 05 | MS | MEDICAID | 09016020 | 05 | MS | MEDICAID | 09106019 | 05 | MS | MEDICAID |