Basic Information
| Provider Information | |||||||||
| NPI: | 1518963123 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MIDSOUTH PAIN TREATMENT CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 245 | ||||||||
| Address2: | |||||||||
| City: | SOUTHAVEN | ||||||||
| State: | MS | ||||||||
| PostalCode: | 386710003 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6623499990 | ||||||||
| FaxNumber: | 6623492620 | ||||||||
| Practice Location | |||||||||
| Address1: | 122 AIRWAYS PL | ||||||||
| Address2: | |||||||||
| City: | SOUTHAVEN | ||||||||
| State: | MS | ||||||||
| PostalCode: | 386715872 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6623499990 | ||||||||
| FaxNumber: | 6623492620 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/28/2005 | ||||||||
| LastUpdateDate: | 12/12/2007 | ||||||||
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| AuthorizedOfficialLastName: | CARNAHAN | ||||||||
| AuthorizedOfficialFirstName: | MELANIE | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | OFFICE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 6623499990 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QA1903X | Y | Ambulatory Health Care Facilities | Clinic/Center | Ambulatory Surgical |
No ID Information.