Basic Information
| Provider Information | |||||||||
| NPI: | 1790890499 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LEY | ||||||||
| FirstName: | PHILLIP | ||||||||
| MiddleName: | BLAINE | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 321359 | ||||||||
| Address2: | |||||||||
| City: | FLOWOOD | ||||||||
| State: | MS | ||||||||
| PostalCode: | 392321359 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6019361395 | ||||||||
| FaxNumber: | 6019336596 | ||||||||
| Practice Location | |||||||||
| Address1: | 1020 N FLOWOOD DR STE A | ||||||||
| Address2: | |||||||||
| City: | FLOWOOD | ||||||||
| State: | MS | ||||||||
| PostalCode: | 392329532 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6019336132 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/20/2006 | ||||||||
| LastUpdateDate: | 08/19/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/19/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2086X0206X | 14786 | MS | Y | Allopathic & Osteopathic Physicians | Surgery | Surgical Oncology |
ID Information
| ID | Type | State | Issuer | Description | 000116599 | 05 | MS | MEDICAID |