1538200209 NPI number — WESLEY PHYSICIAN SERVICES LLC

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1538200209 NPI number — WESLEY PHYSICIAN SERVICES LLC

Employer Identification Number (EIN):

Provider Organization Name:

WESLEY PHYSICIAN SERVICES LLC

Provider Last Name:

Provider First Name:

Provider Middle Name:

Provider Name Prefix Text:

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Provider Credential Text:

Provider Gender Code:

Provider Other Organization Name:

Provider Other Organization Name Type Code:

Provider Other Last Name:

Provider Other First Name:

Provider Other Middle Name:

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Provider Other Last Name Type Code:

NPI Number:

1538200209

Entity Type Code:

Organization

Replacement NPI:

Last Update Date:

06/03/2022

NPI Deactivation Reason Code:

NPI Deactivation Date:

NPI Reactivation Date:

Provider First Line Business Mailing Address:

PO BOX 689022

Provider Second Line Business Mailing Address:

Provider Business Mailing Address City Name:

FRANKLIN

Provider Business Mailing Address State Name:

TN

Provider Business Mailing Address Postal Code:

37068-9022

Provider Business Mailing Address Country Code:

US

Provider Business Mailing Address Telephone Number:

615-465-7361

Provider Business Mailing Address Fax Number:

615-628-6877

Provider First Line Business Practice Location Address:

5001 HARDY ST

Provider Second Line Business Practice Location Address:

Provider Business Practice Location Address City Name:

HATTIESBURG

Provider Business Practice Location Address State Name:

MS

Provider Business Practice Location Address Postal Code:

39402-1308

Provider Business Practice Location Address Country Code:

US

Provider Business Practice Location Address Telephone Number:

601-268-8155

Provider Business Practice Location Address Fax Number:

601-261-0508

Provider Enumeration Date:

02/08/2007

Authorized Official Last Name:

JACKSON

Authorized Official First Name:

JENNIFER

Authorized Official Middle Name:

L

Authorized Official Title or Position:

SENIOR DIRECTOR PROVIDER ENROLLMENT

Authorized Official Telephone Number:

615-465-7000

• Taxonomy code: 101YP2500X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
• Taxonomy code: 103T00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
• Taxonomy code: 104100000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
• Taxonomy code: 1041C0700X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
• Taxonomy code: 207Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
• Taxonomy code: 207QA0401X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
• Taxonomy code: 207R00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
• Taxonomy code: 207RC0000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
• Taxonomy code: 207RI0011X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
• Taxonomy code: 207T00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
• Taxonomy code: 207UN0901X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
• Taxonomy code: 208000000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
• Taxonomy code: 2080A0000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
• Taxonomy code: 2084F0202X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
• Taxonomy code: 208G00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

• Identifier: 06476518 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".
• Identifier: 01726273 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".
• Identifier: 02639565 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".
• Identifier: 02706278 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".
• Identifier: 08883556 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".
• Identifier: 02606764 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".
• Identifier: 06827312 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".
• Identifier: 07236720 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".
• Identifier: 09776308 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".
• Identifier: 05925779 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".
• Identifier: 03277572 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".
• Identifier: 04727870 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".
• Identifier: 01505019 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".
• Identifier: 08955318 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".
• Identifier: 01080271 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".
• Identifier: 07687071 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".
• Identifier: 09236762 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".