1316558893 NPI number — MISSISSIPPI PAIN MANAGEMENT, PLLC

Table of content: (NPI 1316558893)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1316558893 NPI number — MISSISSIPPI PAIN MANAGEMENT, PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MISSISSIPPI PAIN MANAGEMENT, PLLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

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:
1316558893
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/10/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
103 LANGDON BND
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MADISON
Provider Business Mailing Address State Name:
MS
Provider Business Mailing Address Postal Code:
39110-7079
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
769-232-0287
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1080 RIVER OAKS DR STE B103
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FLOWOOD
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
39232-7602
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
601-566-1375
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/10/2020

Additional Information

Authorized Official

Authorized Official Last Name:
ADAMS
Authorized Official First Name:
JOHN
Authorized Official Middle Name:
B
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
601-566-1375

Provider Taxonomy Codes

  • Taxonomy code: 208VP0014X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QP3300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 00120868 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".




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