# SOUTH CENTRAL REGIONAL MEDICAL CENTER

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- **Entity:** Organization
- **Status:** Active
- **Other names:** Ellisville Medical Clinic
- **Organization subpart:** No

## Provider details

- **NPI number:** 1942554761
- **Authorized official:** MR. JAMES T CANIZARO (C.F.O. / VICE PRESIDENT)
- **Authorized official phone:** (601) 399-6139

## Contact information

- **Practice address:** 1203 AVENUE B, ELLISVILLE, MS 39437-2080
- **Practice address phone:** (601) 477-8553
- **Practice address fax:** (601) 477-9158
- **Mailing address:** 1203 AVENUE B, ELLISVILLE, MS 39437-2080
- **Mailing address phone:** (601) 477-8553
- **Mailing address fax:** (601) 477-9158

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 207Q00000X | Family Medicine Physician | — | NULL | Yes |
| 207Q00000X | Family Medicine Physician | — | — | Yes |
| 207V00000X | Obstetrics & Gynecology Physician | — | NULL | — |
| 207V00000X | Obstetrics & Gynecology Physician | — | — | — |
| 2080A0000X | Pediatric Adolescent Medicine Physician | — | NULL | — |
| 2080A0000X | Pediatric Adolescent Medicine Physician | — | — | — |

## Other

- **Enumeration date:** 10/31/2012
- **Last updated:** 10/31/2012