1891978953 NPI number — DRG FAYETTE PLLC

Table of content: (NPI 1831693340)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1891978953 NPI number — DRG FAYETTE PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DRG FAYETTE 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:
1891978953
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/15/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5903 RIDGEWOOD RD
Provider Second Line Business Mailing Address:
SUITE 340
Provider Business Mailing Address City Name:
JACKSON
Provider Business Mailing Address State Name:
MS
Provider Business Mailing Address Postal Code:
39211-3700
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
601-899-3340
Provider Business Mailing Address Fax Number:
601-899-3343

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
225 COMMUNITY DRIVE
Provider Second Line Business Practice Location Address:
OFF HWY 61
Provider Business Practice Location Address City Name:
FAYETTE
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
39069
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
601-786-6676
Provider Business Practice Location Address Fax Number:
601-786-6678
Provider Enumeration Date:
12/12/2007

Additional Information

Authorized Official

Authorized Official Last Name:
OLUTADE
Authorized Official First Name:
TUNDE
Authorized Official Middle Name:
Authorized Official Title or Position:
MEMBER
Authorized Official Telephone Number:
601-899-3340

Provider Taxonomy Codes

  • Taxonomy code: 261QE0700X , 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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