NPIMap

Organization Active NPI

South Central Regional Medical Center

Doing business as Ellisville Medical Clinic

  • Family Medicine Physician
  • Ellisville, MS
National Provider Identifier
1942554761
Registry record updated Oct 31, 2012
On this page

Key facts

NPPES NPI Registry
Primary specialty
Family Medicine PhysicianTaxonomy code 207Q00000X
Legal business name
SOUTH CENTRAL REGIONAL MEDICAL CENTER
Doing business as
Ellisville Medical Clinic
Practice address
1203 Avenue B
Ellisville, MS 39437-2080
Phone
(601) 477-8553
Fax
(601) 477-9158
NPI assigned
Oct 31, 2012
Last updated
Oct 31, 2012By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Oct 31, 2012

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Mr. James T Canizaro
Title
C.F.O. / Vice President
Phone
(601) 399-6139

Specialties & licenses 3

Specialty (taxonomy)CodeLicenseStatePrimary
Family Medicine Physician 207Q00000X NU Primary
Obstetrics & Gynecology Physician 207V00000X NU
Pediatric Adolescent Medicine Physician 2080A0000X NU

Addresses

Primary practice location

1203 Avenue B
Ellisville, MS 39437-2080

Mailing address

1203 Avenue B
Ellisville, MS 39437-2080
Phone (601) 477-8553

Other identifiers 1

IdentifierTypeStateIssuer
09014135MedicaidMS

Other names 1

  • Ellisville Medical Clinic Doing business as

National Provider Directory

National Provider Directory
Tax ID family
South Central Reg Med C27 organizations share this tax ID, including this one

Other organizations with this tax ID 26

Organizations that report the same tax identification number in the National Provider Directory.

View all 26

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1351641600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1351641600000",
    "number": "1942554761",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1203 AVENUE B",
            "city": "ELLISVILLE",
            "state": "MS",
            "postal_code": "394372080",
            "telephone_number": "601-477-8553",
            "fax_number": "601-477-9158"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1203 AVENUE B",
            "city": "ELLISVILLE",
            "state": "MS",
            "postal_code": "394372080",
            "telephone_number": "601-477-8553",
            "fax_number": "601-477-9158"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "SOUTH CENTRAL REGIONAL MEDICAL CENTER",
        "organizational_subpart": "NO",
        "enumeration_date": "2012-10-31",
        "last_updated": "2012-10-31",
        "status": "A",
        "authorized_official_last_name": "CANIZARO",
        "authorized_official_first_name": "JAMES",
        "authorized_official_middle_name": "T",
        "authorized_official_title_or_position": "C.F.O. / VICE PRESIDENT",
        "authorized_official_telephone_number": "601-399-6139",
        "authorized_official_name_prefix": "Mr."
    },
    "taxonomies": [
        {
            "code": "207Q00000X",
            "taxonomy_group": "",
            "desc": "Family Medicine",
            "state": "NU",
            "license": null,
            "primary": true
        },
        {
            "code": "207V00000X",
            "taxonomy_group": "",
            "desc": "Obstetrics & Gynecology",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "2080A0000X",
            "taxonomy_group": "",
            "desc": "Pediatrics, Adolescent Medicine",
            "state": "NU",
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "09014135",
            "state": "MS"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Ellisville Medical Clinic",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Ellisville, MS

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Oct 31, 2012; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.