Basic Information
| Provider Information | |||||||||
| NPI: | 1790262681 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MIDSOUTH TRANSITIONS MEDICAL GROUP | ||||||||
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| OtherOrganizationName: | MIDSOUTH TRANSITIONS MEDICAL GROUP | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9001 DANUBE AVE | ||||||||
| Address2: | |||||||||
| City: | TEXARKANA | ||||||||
| State: | TX | ||||||||
| PostalCode: | 755039305 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9037333729 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3002 MOORES LN | ||||||||
| Address2: | |||||||||
| City: | TEXARKANA | ||||||||
| State: | TX | ||||||||
| PostalCode: | 755032204 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4302004350 | ||||||||
| FaxNumber: | 8334912722 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/24/2018 | ||||||||
| LastUpdateDate: | 11/09/2020 | ||||||||
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| AuthorizedOfficialLastName: | WILLIAMSON | ||||||||
| AuthorizedOfficialFirstName: | COY | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 9037333729 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 11/09/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133V00000X | N | 193200000X MULTI-SPECIALTY GROUP | Dietary & Nutritional Service Providers | Dietitian, Registered | 207P00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine | 207QG0300X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | Geriatric Medicine | 208100000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation | 208D00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | General Practice | 251E00000X | N | Agencies | Home Health | 251F00000X | N | Agencies | Home Infusion | 363LA2200X | AP115441 | TX | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health | 363LF0000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 207RG0300X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Geriatric Medicine |
No ID Information.