Basic Information
| Provider Information | |||||||||
| NPI: | 1801884234 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HENSLEY | ||||||||
| FirstName: | SAMUEL | ||||||||
| MiddleName: | D | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2510 LAKELAND DR | ||||||||
| Address2: | |||||||||
| City: | FLOWOOD | ||||||||
| State: | MS | ||||||||
| PostalCode: | 392329513 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6013551234 | ||||||||
| FaxNumber: | 6013263559 | ||||||||
| Practice Location | |||||||||
| Address1: | 2510 LAKELAND DR | ||||||||
| Address2: | |||||||||
| City: | FLOWOOD | ||||||||
| State: | MS | ||||||||
| PostalCode: | 392329513 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6013551234 | ||||||||
| FaxNumber: | 6013263559 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/10/2005 | ||||||||
| LastUpdateDate: | 09/20/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207ZN0500X | 12771 | MS | N | Allopathic & Osteopathic Physicians | Pathology | Neuropathology | 207ZP0102X | 12771 | MS | Y | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology |
ID Information
| ID | Type | State | Issuer | Description | 00117060 | 05 | MS | MEDICAID |