Basic Information
| Provider Information | |||||||||
| NPI: | 1457857062 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | OCHSNER MISSISSIPPI, LLC | ||||||||
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| OtherOrganizationName: | OCHSNER HEALTH CENTER FOR CHILDREN-PEDIATRIC SPECIALTIES-MCCOMB | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1514 JEFFERSON HWY | ||||||||
| Address2: | |||||||||
| City: | NEW ORLEANS | ||||||||
| State: | LA | ||||||||
| PostalCode: | 701212429 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5048424000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 309 LLEWELLYN AVE | ||||||||
| Address2: | |||||||||
| City: | MCCOMB | ||||||||
| State: | MS | ||||||||
| PostalCode: | 396482703 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5048423900 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/03/2018 | ||||||||
| LastUpdateDate: | 04/03/2018 | ||||||||
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| AuthorizedOfficialLastName: | JOINT | ||||||||
| AuthorizedOfficialFirstName: | RICHARD | ||||||||
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| AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 5047034127 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | OCHSNER MISSISSIPPI, LLC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 09627255 | 05 | MS | MEDICAID |