Provider Demographics
NPI:1083657381
Name:SOUTH CENTRAL REGIONAL MEDICAL CENTER
Entity type:Organization
Organization Name:SOUTH CENTRAL REGIONAL MEDICAL CENTER
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:THOMAS
Authorized Official - Last Name:CANIZARO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-399-6139
Mailing Address - Street 1:PO BOX 607
Mailing Address - Street 2:
Mailing Address - City:LAUREL
Mailing Address - State:MS
Mailing Address - Zip Code:39441-0607
Mailing Address - Country:US
Mailing Address - Phone:601-426-4030
Mailing Address - Fax:601-426-4034
Practice Address - Street 1:1220 JEFFERSON ST
Practice Address - Street 2:RX SUITE 002
Practice Address - City:LAUREL
Practice Address - State:MS
Practice Address - Zip Code:39440-4355
Practice Address - Country:US
Practice Address - Phone:601-426-4030
Practice Address - Fax:601-426-4909
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SOUTH CENTRAL REGIONAL MEDICAL CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-06-14
Last Update Date:2025-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0003X, 3336L0003X
MS02111/3.13336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No333600000XSuppliersPharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00330146Medicaid
2043274OtherPK