Basic Information
Provider Information
NPI: 1821336603
EntityType: 2
ReplacementNPI:  
OrganizationName: SOUTH CENTRAL REGIONAL MEDICAL CENTER
LastName:  
FirstName:  
MiddleName:  
NamePrefix:  
NameSuffix:  
Credential:  
OtherOrganizationName: LAUREL SURGERY CLINIC
OtherOrganizationType: 3
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: PO BOX 607
Address2:  
City: LAUREL
State: MS
PostalCode: 394410607
CountryCode: US
TelephoneNumber: 6016497802
FaxNumber: 6014287841
Practice Location
Address1: 1007 JEFFERSON ST
Address2:  
City: LAUREL
State: MS
PostalCode: 394404350
CountryCode: US
TelephoneNumber: 6016497802
FaxNumber: 6014287841
Other Information
ProviderEnumerationDate: 01/29/2013
LastUpdateDate: 01/29/2013
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode:  
AuthorizedOfficialLastName: CANIZARO
AuthorizedOfficialFirstName: JAMES
AuthorizedOfficialMiddleName: T
AuthorizedOfficialTitleorPosition: CFO/VP OF FINANCE
AuthorizedOfficialTelephone: 6013996139
IsSoleProprietor:  
IsOrganizationSubpart: N
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential: CPA
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
208600000X  Y193400000X SINGLE SPECIALTY GROUPAllopathic & Osteopathic PhysiciansSurgery 

No ID Information.


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