1053419820 NPI number — SUSAN D BOBO

Table of content: SUSAN D BOBO (NPI 1053419820)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1053419820 NPI number — SUSAN D BOBO

Organization/Personal Information

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

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1053419820
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/13/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 4128
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MERIDIAN
Provider Business Mailing Address State Name:
MS
Provider Business Mailing Address Postal Code:
39304-4128
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
601-581-8482
Provider Business Mailing Address Fax Number:
601-483-5543

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1818 COLLEGE DRIVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MERIDIAN
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
39307-5429
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
601-581-8482
Provider Business Practice Location Address Fax Number:
601-483-5543
Provider Enumeration Date:
09/20/2006

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: 363LP0808X , with the licence number:  R802552 , 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: 07526012 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".




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