1699765818 NPI number — SUSAN JENAY NEELY DO

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1699765818 NPI number — SUSAN JENAY NEELY DO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
NEELY
Provider First Name:
SUSAN
Provider Middle Name:
JENAY
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DO
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
NEELY
Provider Other First Name:
SUSAN
Provider Other Middle Name:
JENAY
Provider Other Name Prefix Text:
DR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
PLLC
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1699765818
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/16/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 10389
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GREENWOOD
Provider Business Mailing Address State Name:
MS
Provider Business Mailing Address Postal Code:
38930-0389
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
662-392-8163
Provider Business Mailing Address Fax Number:
601-944-9780

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
209 E JEFFERSON AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GREENWOOD
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
38930-3649
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
662-392-8163
Provider Business Practice Location Address Fax Number:
601-944-9780
Provider Enumeration Date:
10/27/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  16690 , registered in the state of MS ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: P00228400 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( MS ) . This identifiers is of the category "OTHER".
  • Identifier: 00121561 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".
  • Identifier: 01588099 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".




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