Basic Information
| Provider Information | |||||||||
| NPI: | 1508426917 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MISSISSIPPI CENTER FOR ADVANCED MEDICINE, PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7731 OLD CANTON RD STE B | ||||||||
| Address2: | |||||||||
| City: | MADISON | ||||||||
| State: | MS | ||||||||
| PostalCode: | 391106115 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6014990935 | ||||||||
| FaxNumber: | 6014990936 | ||||||||
| Practice Location | |||||||||
| Address1: | 2053 GAUSE BLVD E STE 200 | ||||||||
| Address2: | |||||||||
| City: | SLIDELL | ||||||||
| State: | LA | ||||||||
| PostalCode: | 704615451 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9852598045 | ||||||||
| FaxNumber: | 6014990936 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/18/2019 | ||||||||
| LastUpdateDate: | 06/18/2019 | ||||||||
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| AuthorizedOfficialLastName: | SULLIVAN | ||||||||
| AuthorizedOfficialFirstName: | SPENCER | ||||||||
| AuthorizedOfficialMiddleName: | K | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO/OWNER | ||||||||
| AuthorizedOfficialTelephone: | 6014990935 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | MISSISSIPPI CENTER FOR ADVANCED MEDICINE, PC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | Y | 193200000X MULTI-SPECIALTY GROUP | Other Service Providers | Specialist |
No ID Information.