Provider Demographics
NPI:1891728382
Name:MISSISSIPPI COAST ENDOSCOPY & AMBULATORY CENTER LLC
Entity type:Organization
Organization Name:MISSISSIPPI COAST ENDOSCOPY & AMBULATORY CENTER LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KATHERINE
Authorized Official - Middle Name:RENEE
Authorized Official - Last Name:JUDKINS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-240-3770
Mailing Address - Street 1:2406 CATALPA AVE
Mailing Address - Street 2:
Mailing Address - City:PASCAGOULA
Mailing Address - State:MS
Mailing Address - Zip Code:39567-1813
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:228-696-0893
Practice Address - Street 1:2406 CATALPA AVE
Practice Address - Street 2:
Practice Address - City:PASCAGOULA
Practice Address - State:MS
Practice Address - Zip Code:39567-1813
Practice Address - Country:US
Practice Address - Phone:228-696-0818
Practice Address - Fax:228-696-0893
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-08
Last Update Date:2023-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS019261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS000050466OtherBCBS
MS0770544Medicaid
MS169127800OtherDEPARTMENT OF LABOR
MS490005347OtherRAILROAD MEDICARE
MS490005347OtherRAILROAD MEDICARE