Basic Information
| Provider Information | |||||||||
| NPI: | 1366014128 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SOUTH MISSISSIPPI WOUND MANAGEMENT LLC | ||||||||
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| OtherOrganizationName: | SOUTH MISSISSIPPI WOUND MANAGEMENT | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1600 N STATE ST STE 400 | ||||||||
| Address2: | |||||||||
| City: | JACKSON | ||||||||
| State: | MS | ||||||||
| PostalCode: | 392021689 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6019441717 | ||||||||
| FaxNumber: | 6019449780 | ||||||||
| Practice Location | |||||||||
| Address1: | 427 HIGHWAY 51 N | ||||||||
| Address2: | |||||||||
| City: | BROOKHAVEN | ||||||||
| State: | MS | ||||||||
| PostalCode: | 396012350 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6018359444 | ||||||||
| FaxNumber: | 6018335210 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/12/2021 | ||||||||
| LastUpdateDate: | 07/14/2021 | ||||||||
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| AuthorizedOfficialLastName: | MARTIN | ||||||||
| AuthorizedOfficialFirstName: | BRADLEY | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 6017576192 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | PA | ||||||||
| NPICertificationDate: | 07/14/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | Y | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Specialist |
No ID Information.