1558588509 NPI number — DR SUSAN JENAY NEELY PLLC

Table of content: (NPI 1558588509)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1558588509 NPI number — DR SUSAN JENAY NEELY PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DR SUSAN JENAY NEELY 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:
6
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:
1558588509
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/04/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 220
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NORTH CARROLLTON
Provider Business Mailing Address State Name:
MS
Provider Business Mailing Address Postal Code:
38947-0220
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
662-237-4525
Provider Business Mailing Address Fax Number:
662-237-9781

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
502 GEORGE ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NORTH CARROLLTON
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
38947-0220
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
662-237-4525
Provider Business Practice Location Address Fax Number:
662-237-9781
Provider Enumeration Date:
04/19/2007

Additional Information

Authorized Official

Authorized Official Last Name:
NEELY
Authorized Official First Name:
SUSAN
Authorized Official Middle Name:
JENAY
Authorized Official Title or Position:
PHYSICIAN
Authorized Official Telephone Number:
662-237-4525

Provider Taxonomy Codes

  • Taxonomy code: 261QP2300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 01588099 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".
  • Identifier: 00121561 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".
  • Identifier: 426493934A . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( MS ) . This identifiers is of the category "OTHER".
  • Identifier: P00228400 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( MS ) . This identifiers is of the category "OTHER".




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