1366845554 NPI number — MISSISSIPPI ANESTHESIA GROUP, LLC

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 1366845554 NPI number — MISSISSIPPI ANESTHESIA GROUP, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MISSISSIPPI ANESTHESIA GROUP, LLC
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:
1366845554
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/01/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2714 W OXFORD LOOP
Provider Second Line Business Mailing Address:
STE 161
Provider Business Mailing Address City Name:
OXFORD
Provider Business Mailing Address State Name:
MS
Provider Business Mailing Address Postal Code:
38655-5711
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
662-550-4299
Provider Business Mailing Address Fax Number:
662-580-4324

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
145 SANCTUARY LN
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CANTON
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
39046-6601
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
601-855-7440
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/01/2014

Additional Information

Authorized Official

Authorized Official Last Name:
SELF
Authorized Official First Name:
GARY
Authorized Official Middle Name:
DWAYNE
Authorized Official Title or Position:
FOUNDER AND PRESIDENT
Authorized Official Telephone Number:
601-668-5628

Provider Taxonomy Codes

  • Taxonomy code: 367500000X , with the licence number:  R598755 , 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)





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