Basic Information
| Provider Information | |||||||||
| NPI: | 1154391068 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WINDMILL | ||||||||
| FirstName: | IAN | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | PHD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2500 N STATE ST | ||||||||
| Address2: | DEPARTMENT OF OTOLARYNGOLOGY | ||||||||
| City: | JACKSON | ||||||||
| State: | MS | ||||||||
| PostalCode: | 392164500 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6019845160 | ||||||||
| FaxNumber: | 6018156985 | ||||||||
| Practice Location | |||||||||
| Address1: | 2500 N STATE ST | ||||||||
| Address2: | DEPARTMENT OF OTOLARYNGOLOGY | ||||||||
| City: | JACKSON | ||||||||
| State: | MS | ||||||||
| PostalCode: | 392164500 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6019845160 | ||||||||
| FaxNumber: | 6018156985 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/24/2006 | ||||||||
| LastUpdateDate: | 01/31/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 231H00000X | 0100 | KY | N | Speech, Language and Hearing Service Providers | Audiologist | 231H00000X | A3324 | MS | Y | Speech, Language and Hearing Service Providers | Audiologist |
ID Information
| ID | Type | State | Issuer | Description | 1085858 | 01 | KY | PASSPORT | OTHER | 70001003 | 05 | KY | MEDICAID | 01531216 | 05 | MS | MEDICAID | 100345580A | 05 | IN | MEDICAID |