Provider Demographics
NPI:1154360501
Name:GULF SOUTH SURGERY CENTER LLC
Entity type:Organization
Organization Name:GULF SOUTH SURGERY CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JASON
Authorized Official - Middle Name:
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:228-818-0563
Mailing Address - Street 1:1206 31ST AVE
Mailing Address - Street 2:
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39501-1804
Mailing Address - Country:US
Mailing Address - Phone:228-864-0008
Mailing Address - Fax:
Practice Address - Street 1:1206 31ST AVE
Practice Address - Street 2:
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39501-1804
Practice Address - Country:US
Practice Address - Phone:228-864-0008
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-04
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS002261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS04608029Medicaid
MS000050762OtherBLUE CROSS BLUE SHIELD
MS362773700OtherOWCP
MSP00064348OtherMEDICARE RAIL ROAD
MS362773700OtherOWCP