Basic Information
| Provider Information | |||||||||
| NPI: | 1740636786 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MISSISSIPPI CENTER FOR ADVANCED MEDICINE PC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | MISSISSIPPI CENTER FOR ADVANCED MEDICINE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7731 OLD CANTON RD | ||||||||
| Address2: | SUITE B | ||||||||
| City: | MADISON | ||||||||
| State: | MS | ||||||||
| PostalCode: | 391106114 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6014990935 | ||||||||
| FaxNumber: | 6014990936 | ||||||||
| Practice Location | |||||||||
| Address1: | 7731 OLD CANTON RD STE B | ||||||||
| Address2: | |||||||||
| City: | MADISON | ||||||||
| State: | MS | ||||||||
| PostalCode: | 391106115 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6014990935 | ||||||||
| FaxNumber: | 6014990936 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/09/2016 | ||||||||
| LastUpdateDate: | 10/05/2016 | ||||||||
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| AuthorizedOfficialLastName: | SULLIVAN | ||||||||
| AuthorizedOfficialFirstName: | SPENCER | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT AND CEO | ||||||||
| AuthorizedOfficialTelephone: | 6018639764 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 333600000X | N | Suppliers | Pharmacy | 3336C0002X | N | Suppliers | Pharmacy | Clinic Pharmacy | 3336C0003X | 14837/1.1 | MS | Y | Suppliers | Pharmacy | Community/Retail Pharmacy |
ID Information
| ID | Type | State | Issuer | Description | 2160699 | 01 | PK | OTHER | 09587750 | 05 | MS | MEDICAID |