Basic Information
| Provider Information | |||||||||
| NPI: | 1477741494 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ANDREW GEORGE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 25 S FOURTH ST | ||||||||
| Address2: | |||||||||
| City: | ROLLING FORK | ||||||||
| State: | MS | ||||||||
| PostalCode: | 391595146 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6628730477 | ||||||||
| FaxNumber: | 6628730742 | ||||||||
| Practice Location | |||||||||
| Address1: | 25 S FOURTH ST | ||||||||
| Address2: | |||||||||
| City: | ROLLING FORK | ||||||||
| State: | MS | ||||||||
| PostalCode: | 391595146 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6628730477 | ||||||||
| FaxNumber: | 6628730742 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/04/2007 | ||||||||
| LastUpdateDate: | 10/04/2007 | ||||||||
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| AuthorizedOfficialLastName: | GEORGE | ||||||||
| AuthorizedOfficialFirstName: | ANDREW | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 6628730477 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 13643 | MS | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 02984093 | 05 | MS | MEDICAID |