1760686299 NPI number — ROSCOE L. DOUGLAS, PH.D., P.A.

Table of content: (NPI 1760686299)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1760686299 NPI number — ROSCOE L. DOUGLAS, PH.D., P.A.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ROSCOE L. DOUGLAS, PH.D., P.A.
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:
1760686299
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 3545
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:
39303-3545
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
601-483-8370
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1207 WHITE OAK DR
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:
39305-1902
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
601-483-8370
Provider Business Practice Location Address Fax Number:
601-482-4248
Provider Enumeration Date:
06/11/2007

Additional Information

Authorized Official

Authorized Official Last Name:
DOUGLAS
Authorized Official First Name:
ROSCOE
Authorized Official Middle Name:
LORMER
Authorized Official Title or Position:
CLINICAL PSYCHOLOGIST
Authorized Official Telephone Number:
601-483-8370

Provider Taxonomy Codes

  • Taxonomy code: 103TC0700X , with the licence number:  139 , 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: 00017960 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1740494434 . This is a "NPI INDIV PROV NUMBER" identifier , issued by the state of ( MS ) . This identifiers is of the category "OTHER".




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