Provider Demographics
NPI:1285911693
Name:SOUTHERN MS HEART CENTER,PA
Entity type:Organization
Organization Name:SOUTHERN MS HEART CENTER,PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:AMY
Authorized Official - Middle Name:E
Authorized Official - Last Name:COUCH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:228-762-1002
Mailing Address - Street 1:4300 HOSPITAL ST STE 102
Mailing Address - Street 2:
Mailing Address - City:PASCAGOULA
Mailing Address - State:MS
Mailing Address - Zip Code:39581-5329
Mailing Address - Country:US
Mailing Address - Phone:228-762-1002
Mailing Address - Fax:228-762-1012
Practice Address - Street 1:7001 HIGHWAY 614
Practice Address - Street 2:
Practice Address - City:HURLEY
Practice Address - State:MS
Practice Address - Zip Code:39555
Practice Address - Country:US
Practice Address - Phone:228-762-1002
Practice Address - Fax:228-762-1012
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-11-14
Last Update Date:2011-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MSCG1009OtherRAILROAD MEDICARE
MS09014546Medicaid
MSCG1009OtherRAILROAD MEDICARE