Basic Information
| Provider Information | |||||||||
| NPI: | 1487866158 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MEADOWS | ||||||||
| FirstName: | TERRY | ||||||||
| MiddleName: | ANN | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 173 K & B LANE | ||||||||
| Address2: | |||||||||
| City: | MAGEE | ||||||||
| State: | MS | ||||||||
| PostalCode: | 39111 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6014694151 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 330 NORTH BROAD ST | ||||||||
| Address2: | |||||||||
| City: | FOREST | ||||||||
| State: | MS | ||||||||
| PostalCode: | 39074 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6014694151 | ||||||||
| FaxNumber: | 6014693681 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/04/2007 | ||||||||
| LastUpdateDate: | 09/19/2016 | ||||||||
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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 | 261QF0400X | 10554 | MS | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
| ID | Type | State | Issuer | Description | 0010446 | 05 | MS | MEDICAID |