Basic Information
| Provider Information | |||||||||
| NPI: | 1477621324 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WINDHAM | ||||||||
| FirstName: | BEVERLY | ||||||||
| MiddleName: | GWEN | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | OLDENQUIST | ||||||||
| OtherFirstName: | GWEN | ||||||||
| OtherMiddleName: | WINDHAM | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | M.D. | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2500 N STATE ST | ||||||||
| Address2: | DIVISION OF GERIATRICS | ||||||||
| City: | JACKSON | ||||||||
| State: | MS | ||||||||
| PostalCode: | 392164500 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6019845610 | ||||||||
| FaxNumber: | 6019845783 | ||||||||
| Practice Location | |||||||||
| Address1: | 2500 NORTH STATE STREET | ||||||||
| Address2: | DEPARTMENT OF MEDICINE DIVISION OF GERIATRICS | ||||||||
| City: | JACKSON | ||||||||
| State: | MS | ||||||||
| PostalCode: | 39216 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6019845610 | ||||||||
| FaxNumber: | 6019845783 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/30/2006 | ||||||||
| LastUpdateDate: | 04/11/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RG0300X | D0056056 | MD | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Geriatric Medicine |
ID Information
| ID | Type | State | Issuer | Description | 08952891 | 05 | MS | MEDICAID |