Basic Information
| Provider Information | |||||||||
| NPI: | 1699765818 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | NEELY | ||||||||
| FirstName: | SUSAN | ||||||||
| MiddleName: | JENAY | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | DO | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | NEELY | ||||||||
| OtherFirstName: | SUSAN | ||||||||
| OtherMiddleName: | JENAY | ||||||||
| OtherNamePrefix: | DR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | PLLC | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 10389 | ||||||||
| Address2: | |||||||||
| City: | GREENWOOD | ||||||||
| State: | MS | ||||||||
| PostalCode: | 389300389 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6623928163 | ||||||||
| FaxNumber: | 6019449780 | ||||||||
| Practice Location | |||||||||
| Address1: | 209 E JEFFERSON AVE | ||||||||
| Address2: | |||||||||
| City: | GREENWOOD | ||||||||
| State: | MS | ||||||||
| PostalCode: | 389303649 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6623928163 | ||||||||
| FaxNumber: | 6019449780 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/27/2005 | ||||||||
| LastUpdateDate: | 07/16/2013 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
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| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 16690 | MS | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | P00228400 | 01 | MS | RAILROAD MEDICARE | OTHER | 00121561 | 05 | MS | MEDICAID | 01588099 | 05 | MS | MEDICAID |